Provider Demographics
NPI:1356361208
Name:FUTCH, MARY MARTHA (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:MARTHA
Last Name:FUTCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9863 OLD PLANK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32220-1335
Mailing Address - Country:US
Mailing Address - Phone:904-783-8613
Mailing Address - Fax:
Practice Address - Street 1:31 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2311
Practice Address - Country:US
Practice Address - Phone:904-259-6259
Practice Address - Fax:904-259-3436
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2517152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620401500Medicaid
FLU25749Medicare UPIN
FL20312AMedicare ID - Type Unspecified