Provider Demographics
NPI:1467654475
Name:DR. MARK D STOVALL, PSC
Entity Type:Organization
Organization Name:DR. MARK D STOVALL, PSC
Other - Org Name:DRS VANCE AND STOVALL, PSC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:502-585-2020
Mailing Address - Street 1:120 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1332
Mailing Address - Country:US
Mailing Address - Phone:502-585-2020
Mailing Address - Fax:502-585-1797
Practice Address - Street 1:120 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1332
Practice Address - Country:US
Practice Address - Phone:502-585-2020
Practice Address - Fax:502-585-1797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCK4506OtherRAILROAD MEDICARE
KY7100158840Medicaid
KY7100158840Medicaid
KY8424Medicare PIN