Provider Demographics
NPI:1891784658
Name:DUMBAULD, MARK A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DUMBAULD
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 1:55 W MARTIN ST
Mailing Address - Street 2:P.O. BOX 47
Mailing Address - City:EAST PALESTINE
Mailing Address - State:OH
Mailing Address - Zip Code:44413-1761
Mailing Address - Country:US
Mailing Address - Phone:330-426-3428
Mailing Address - Fax:330-426-3428
Practice Address - Street 1:55 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:EAST PALESTINE
Practice Address - State:OH
Practice Address - Zip Code:44413-1761
Practice Address - Country:US
Practice Address - Phone:330-426-3428
Practice Address - Fax:330-426-3428
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0843716Medicaid
OH0843716Medicaid
DU0702691Medicare PIN
U21787Medicare UPIN