Provider Demographics
NPI:1558537134
Name:MARK A MOTLEY OD INC
Entity Type:Organization
Organization Name:MARK A MOTLEY OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-483-3720
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-0277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:423 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-1335
Practice Address - Country:US
Practice Address - Phone:419-483-3720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3300-T018152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00164996OtherANTHEM BLUE CROSS AND BLUE SHIELD
OH00130216OtherANTHEM BLUE CROSS AND BLUE SHIELD
OH1750494530OtherBWC BUREAU OF WORKER'S COMPENSATION
OH2774494380001OtherMEDICAL MUTUAL
OH791580458OtherRR MEDICARE
OH0333704Medicaid
OH=========OtherAETNA
OH0333704Medicaid
OH00164996OtherANTHEM BLUE CROSS AND BLUE SHIELD
OH0159490001Medicare NSC
OH791580458OtherRR MEDICARE