Provider Demographics
NPI:1104963099
Name:MRACHEK, MARTY (OD)
Entity type:Individual
Prefix:DR
First Name:MARTY
Middle Name:
Last Name:MRACHEK
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 1:537 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5859
Mailing Address - Country:US
Mailing Address - Phone:701-255-8490
Mailing Address - Fax:701-255-9349
Practice Address - Street 1:537 S. 7TH ST
Practice Address - Street 2:C/O NATIONWIDE VISION
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5859
Practice Address - Country:US
Practice Address - Phone:701-255-8490
Practice Address - Fax:701-255-9349
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND602152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDP00136359OtherRAILROAD MEDICARE
NDU86250Medicare UPIN
NDN20865Medicare ID - Type Unspecified