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General NPI Number Information
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NPI Number | 1124306279
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Entity Type | Individual
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Provider Name | MARK JOSEPH MEDLEY II O.D.
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Gender | Male
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Dates
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Enumeration Date | 07/22/2011
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Last Update Date | 07/25/2023
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Provider Practice Location Address
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Address Line | USA MEDDAC FORT DRUM 11050 MT. BELVEDERE BLVD.
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City | FORT DRUM
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State | NY
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Zip | 13602
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Country | US
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Telephone | 315-772-2778
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Fax |
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Provider Business Mailing Address
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Address Line | USA MEDDAC FORT DRUM 11050 MT. BELVEDERE BLVD.
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City | FORT DRUM
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State | NY
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Zip | 13602
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Country | US
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Telephone | 157-722-7783
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2987
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License Number State | TN
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