Provider Demographics
NPI:1417042201
Name:YODER, MARK ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:YODER
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 1:107 N MAIN ST
Mailing Address - Street 2:PO BOX 123
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-1245
Mailing Address - Country:US
Mailing Address - Phone:419-358-6076
Mailing Address - Fax:419-358-7736
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-1245
Practice Address - Country:US
Practice Address - Phone:419-358-6076
Practice Address - Fax:419-358-7736
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4155152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0743664Medicaid
OH18008277OtherRAILROAD MEDICARE
OHCC0091OtherGROUP RAILROAD
OH18008277OtherRAILROAD MEDICARE
OHYO0654191Medicare PIN
OHU20313Medicare UPIN