Provider Demographics
NPI:1407849516
Name:POPHAL, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:POPHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-626-6161
Mailing Address - Fax:419-502-3511
Practice Address - Street 1:29001 CEDAR RD STE 110
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4041
Practice Address - Country:US
Practice Address - Phone:216-382-8022
Practice Address - Fax:216-382-7667
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-9490-P207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
180028844OtherRAILROAD MEDICARE
OH1193810001OtherDMERC MEDICARE
OH34-1844400OtherTAX ID#
OH2027612Medicaid
OHH140671OtherMEDICARE
OH0822286Medicare PIN
OH34-1844400OtherTAX ID#
1193810001Medicare NSC
OH0822281Medicare ID - Type UnspecifiedMEDICARE ID
180028844OtherRAILROAD MEDICARE