Provider Demographics
NPI:1124589346
Name:MARCELLUS, CARLINE (LDO)
Entity Type:Individual
Prefix:
First Name:CARLINE
Middle Name:
Last Name:MARCELLUS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 PENINSULA BLVD # 5368
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1200
Mailing Address - Country:US
Mailing Address - Phone:516-881-3484
Mailing Address - Fax:
Practice Address - Street 1:1220 PENINSULA BLVD # 5368
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1200
Practice Address - Country:US
Practice Address - Phone:516-881-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009023156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician