Provider Demographics
NPI:1750494530
Name:MOTLEY, MARK ALLEN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:MOTLEY
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1355 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811
Practice Address - Country:US
Practice Address - Phone:419-483-7685
Practice Address - Fax:419-483-4694
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.003300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0333704Medicaid
OH1750494530OtherOHIO BWC
OH791580458OtherRAILROAD MEDICARE
00130216OtherANTHEM
OH00164996OtherANTHEM
OH0159490001Medicare NSC
OH1750494530OtherOHIO BWC
OH0333704Medicaid