Provider Demographics
NPI:1205839552
Name:GERSMAN, MARK ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANDREW
Last Name:GERSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4676 DOUGLAS CIR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3619
Mailing Address - Country:US
Mailing Address - Phone:330-494-1116
Mailing Address - Fax:330-494-0276
Practice Address - Street 1:4676 DOUGLAS CIR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3619
Practice Address - Country:US
Practice Address - Phone:330-494-1116
Practice Address - Fax:330-494-0276
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.060285207WX0107X
OH35060285207W00000X
WV18631207W00000X
PAMD057570L207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036611OtherMCR # OTHER TAX ID
WV0096237000Medicaid
OH180041827OtherRRMCR # OTHER TAX ID
PA0015118570004Medicaid
OH0975753Medicaid
WV0096237000Medicaid
OH0731713Medicare PIN
OH4036611OtherMCR # OTHER TAX ID
PA0015118570004Medicaid
OH820000079Medicare PIN
OH0731717Medicare PIN
WV0731719Medicare PIN