Provider Demographics
NPI:1316902661
Name:KAUFMAN, J MARK (OD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:MARK
Last Name:KAUFMAN
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:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:SUGARCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:44681-0245
Mailing Address - Country:US
Mailing Address - Phone:330-852-2512
Mailing Address - Fax:
Practice Address - Street 1:233 N. FACTORY ST.
Practice Address - Street 2:
Practice Address - City:SUGARCREEK
Practice Address - State:OH
Practice Address - Zip Code:44681
Practice Address - Country:US
Practice Address - Phone:330-852-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3807/220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KA0606651Medicare PIN