Provider Demographics
NPI:1720136351
Name:FIELDS, MARK JEFFERY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFERY
Last Name:FIELDS
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 1:3704 RIDGE VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2941
Mailing Address - Country:US
Mailing Address - Phone:859-543-9474
Mailing Address - Fax:
Practice Address - Street 1:820 EASTERN BYP
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2512
Practice Address - Country:US
Practice Address - Phone:859-625-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1315 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013159Medicaid
KY9364601Medicare ID - Type Unspecified
KYU57815Medicare UPIN