Provider Demographics
NPI:1164586467
Name:MONTEROLA, MARISA K (OD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:K
Last Name:MONTEROLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23356 NE 25TH WAY
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-8937
Mailing Address - Country:US
Mailing Address - Phone:425-868-3541
Mailing Address - Fax:425-868-3541
Practice Address - Street 1:133 N 85TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-3601
Practice Address - Country:US
Practice Address - Phone:206-783-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3028TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2028165Medicaid
WA2028165Medicaid
WAAB39309Medicare ID - Type Unspecified