Provider Demographics
NPI:1487640637
Name:SCHMIDT, MARK EVERETT (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EVERETT
Last Name:SCHMIDT
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 1:460 RONA PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-1118
Mailing Address - Country:US
Mailing Address - Phone:419-628-8267
Mailing Address - Fax:
Practice Address - Street 1:460 RONA PKWY
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-1118
Practice Address - Country:US
Practice Address - Phone:937-833-4054
Practice Address - Fax:937-833-4055
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4047/T108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0766523Medicaid
OH0766523Medicaid
OHT80601Medicare UPIN
OH0225100001Medicare NSC