Provider Demographics
NPI:1053476788
Name:MARBUN, RIOLAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RIOLAN
Middle Name:
Last Name:MARBUN
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 91519
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92169-3519
Mailing Address - Country:US
Mailing Address - Phone:615-604-6101
Mailing Address - Fax:
Practice Address - Street 1:1288 CAMINO DEL RIO N
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1511
Practice Address - Country:US
Practice Address - Phone:619-500-6688
Practice Address - Fax:619-500-6689
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13678152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3590020Medicare PIN
CAEQ844AMedicare PIN
TNU92361Medicare UPIN