Provider Demographics
NPI:1609874221
Name:MARK, MARTIN O (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:O
Last Name:MARK
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 1:1966 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3602
Mailing Address - Country:US
Mailing Address - Phone:212-534-1020
Mailing Address - Fax:
Practice Address - Street 1:1966 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3602
Practice Address - Country:US
Practice Address - Phone:212-534-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV002752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00329979Medicaid
NY00329979Medicaid