Provider Demographics
NPI:1831173590
Name:FAST, MARK JARED (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JARED
Last Name:FAST
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 1:3816 CENTER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2905
Mailing Address - Country:US
Mailing Address - Phone:503-588-5513
Mailing Address - Fax:503-588-5470
Practice Address - Street 1:3816 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2905
Practice Address - Country:US
Practice Address - Phone:503-588-5513
Practice Address - Fax:503-588-5470
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2986ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR159539Medicare PIN
ORR131730Medicare PIN