Provider Demographics
NPI:1912097825
Name:FEDER, MARK S (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:FEDER
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 1:5 EVERSLEY AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5821
Mailing Address - Country:US
Mailing Address - Phone:203-853-1010
Mailing Address - Fax:
Practice Address - Street 1:5 EVERSLEY AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5821
Practice Address - Country:US
Practice Address - Phone:203-853-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1047152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT090001047CT01OtherBLUE CROSS ID #
CT0177510001OtherDMERC NSC#
CT090001047CT02OtherBLUE CROSS AS OF 2009
CT1047OtherLICENSE NUMBER
CT263271976OtherUHC
CTP464831OtherOXFORD
CT090001047CT02OtherBLUE CROSS AS OF 2009
CTP464831OtherOXFORD
CT6312120001Medicare NSC