Provider Demographics
NPI:1134226723
Name:MARTINDALE, MARK W (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:MARTINDALE
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 1:201 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-2027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-2027
Practice Address - Country:US
Practice Address - Phone:662-837-7186
Practice Address - Fax:662-837-0198
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011572Medicaid
MS00087830Medicaid
0143260001Medicare ID - Type Unspecified
MS00087830Medicaid
C00869Medicare ID - Type Unspecified