Provider Demographics
NPI:1811171473
Name:POLLACK, MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:POLLACK
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 1:171 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-2418
Mailing Address - Country:US
Mailing Address - Phone:908-852-6623
Mailing Address - Fax:
Practice Address - Street 1:171 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-2418
Practice Address - Country:US
Practice Address - Phone:908-852-6623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA003929152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0000675625Medicare NSC