Provider Demographics
NPI:1275530834
Name:HERSHOWITZ, MARK (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HERSHOWITZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 PUBLIC SQ STE 102
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2674
Mailing Address - Country:US
Mailing Address - Phone:315-681-6379
Mailing Address - Fax:
Practice Address - Street 1:53 PUBLIC SQ STE 102
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2674
Practice Address - Country:US
Practice Address - Phone:315-681-6379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52833AOtherMEDICARE PTAN
NYTUV007244OtherNY STATE LICENSE
NY52833AOtherMEDICARE PTAN