Provider Demographics
NPI:1174685564
Name:MARCOLIVIO, MARYANNE (OD)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:MARCOLIVIO
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 1:270 LAGUNA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2521
Mailing Address - Country:US
Mailing Address - Phone:714-525-2375
Mailing Address - Fax:714-871-9280
Practice Address - Street 1:270 LAGUNA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2521
Practice Address - Country:US
Practice Address - Phone:714-525-2375
Practice Address - Fax:714-871-9280
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9576 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU78453Medicare UPIN