Provider Demographics
NPI:1174592646
Name:DEA, MARC (OD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:DEA
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 1:2687 CASTRO VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5409
Mailing Address - Country:US
Mailing Address - Phone:510-581-1553
Mailing Address - Fax:510-581-1929
Practice Address - Street 1:2687 CASTRO VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5409
Practice Address - Country:US
Practice Address - Phone:510-581-1553
Practice Address - Fax:510-581-1929
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11124T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000960Medicaid
CAGR0022890Medicaid
CAZZZ15747ZMedicare ID - Type Unspecified
CAGSD000960Medicaid
CAGR0022890Medicaid
CASD0111240Medicare PIN
CACA119850Medicare UPIN