Provider Demographics
NPI:1558438580
Name:KAPUSTA, MARK F (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:KAPUSTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:30851 EUCLID AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094
Mailing Address - Country:US
Mailing Address - Phone:440-944-5155
Mailing Address - Fax:440-943-9460
Practice Address - Street 1:30851 EUCLID AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-944-5155
Practice Address - Fax:440-943-9460
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH3511T508152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0474259Medicaid
OH0474259Medicaid