Provider Demographics
NPI:1609823905
Name:STOVALL, MARK D (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:STOVALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:120 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1332
Practice Address - Country:US
Practice Address - Phone:502-585-2020
Practice Address - Fax:502-585-1797
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY1147DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY410048660OtherRAILROAD MEDICARE
KY77011476Medicaid
KY9334602Medicare PIN
KY410048660OtherRAILROAD MEDICARE