Provider Demographics
NPI:1215113667
Name:MARK M. AINSWORTH
Entity type:Organization
Organization Name:MARK M. AINSWORTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:AINSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-866-9667
Mailing Address - Street 1:394 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-2026
Mailing Address - Country:US
Mailing Address - Phone:315-866-9667
Mailing Address - Fax:315-866-9668
Practice Address - Street 1:394 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2026
Practice Address - Country:US
Practice Address - Phone:315-866-9667
Practice Address - Fax:315-866-9668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005303-1152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4555820001Medicare NSC