Provider Demographics
NPI:1508122854
Name:MARY M FUTCH OD PA
Entity Type:Organization
Organization Name:MARY M FUTCH OD PA
Other - Org Name:BAKER VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARTHA
Authorized Official - Last Name:FUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-259-6259
Mailing Address - Street 1:31 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2311
Mailing Address - Country:US
Mailing Address - Phone:904-259-6259
Mailing Address - Fax:904-259-3436
Practice Address - Street 1:31 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2311
Practice Address - Country:US
Practice Address - Phone:904-259-6259
Practice Address - Fax:904-259-3436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2517152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20312OtherBCBS
FL1356361208OtherNPI
OC0002221OtherPHARMACY CERTIFICATION
FL1508122854OtherNPI
FL620401500Medicaid
FL20312AMedicare UPIN
FL1508122854OtherNPI