Provider Demographics
NPI:1225165590
Name:MARSHAK, JEFFREY ELLIS (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ELLIS
Last Name:MARSHAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:390 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE#1100
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4475
Mailing Address - Country:US
Mailing Address - Phone:310-641-1700
Mailing Address - Fax:310-535-2155
Practice Address - Street 1:390 N SEPULVEDA BLVD
Practice Address - Street 2:SUITE# 1100
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4475
Practice Address - Country:US
Practice Address - Phone:310-641-1700
Practice Address - Fax:310-535-2155
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5564 TPL152W00000X
CA5564T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10040Medicare UPIN
CAFP758ZMedicare PIN