Provider Demographics
NPI:1124306279
Name:MEDLEY, MARK JOSEPH II (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:MEDLEY
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:USA MEDDAC FORT DRUM
Mailing Address - Street 2:11050 MT. BELVEDERE BLVD.
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:157-722-7783
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC FORT DRUM
Practice Address - Street 2:11050 MT. BELVEDERE BLVD.
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN2987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN