Provider Demographics
NPI:1508937079
Name:LYNN, MARK EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:LYNN
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 1:4802 ALBRECHT CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-5529
Mailing Address - Country:US
Mailing Address - Phone:502-308-5966
Mailing Address - Fax:502-743-4426
Practice Address - Street 1:801 EDITH RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2280
Practice Address - Country:US
Practice Address - Phone:502-308-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1072DT152WV0400X, 152W00000X
IN18002494A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010726Medicaid
TN77010723Medicaid
KY9365916Medicare PIN
IN196350LMedicare PIN
KY0550812Medicare PIN
IN1800348450AMedicaid
KY0550712Medicare PIN