Provider Demographics
NPI:1356312888
Name:BIDLACK, MARK ALAN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:BIDLACK
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 1:1183 WESTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891
Mailing Address - Country:US
Mailing Address - Phone:419-238-9244
Mailing Address - Fax:419-238-4695
Practice Address - Street 1:1183 WESTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891
Practice Address - Country:US
Practice Address - Phone:419-238-9244
Practice Address - Fax:419-238-4695
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3921/T1214152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2445296Medicaid
OH61143605100OtherBWC
OH000000314744OtherBCBS
OHP00121396Medicare PIN
T80643Medicare UPIN
OH5007540001Medicare NSC
OH0615204Medicare PIN