Provider Demographics
NPI:1245228402
Name:MAH, MARVIN C (OD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:C
Last Name:MAH
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 1:1556 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5100
Mailing Address - Country:US
Mailing Address - Phone:510-438-0508
Mailing Address - Fax:513-661-2362
Practice Address - Street 1:1556 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-5100
Practice Address - Country:US
Practice Address - Phone:510-438-0508
Practice Address - Fax:513-661-2362
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA006996T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0069960TMedicaid
CAT10448Medicare UPIN
CASD0069960TMedicaid