Provider Demographics
NPI:1114114592
Name:MARQUARDT, THOMAS JAY (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAY
Last Name:MARQUARDT
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 90
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CO
Mailing Address - Zip Code:80446-0090
Mailing Address - Country:US
Mailing Address - Phone:970-887-2459
Mailing Address - Fax:
Practice Address - Street 1:60 NORTH THIRD STREET
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446-0090
Practice Address - Country:US
Practice Address - Phone:970-887-2459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPTOMETRY902152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79873Medicare UPIN