Provider Demographics
NPI:1053392696
Name:SHERSTINSKY, MARK (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHERSTINSKY
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 1:3916 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-1307
Mailing Address - Country:US
Mailing Address - Phone:323-234-9137
Mailing Address - Fax:323-235-6203
Practice Address - Street 1:3916 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037
Practice Address - Country:US
Practice Address - Phone:323-234-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT006400152W00000X
CA12180TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA822570Medicaid
NYU87495Medicare UPIN