Provider Demographics
NPI:1245386481
Name:MARSHALL, JON BARRY (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:BARRY
Last Name:MARSHALL
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 1:450 E PASS RD STE 9
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3212
Mailing Address - Country:US
Mailing Address - Phone:228-896-8619
Mailing Address - Fax:228-896-8619
Practice Address - Street 1:450 E PASS RD STE 9
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3212
Practice Address - Country:US
Practice Address - Phone:228-896-8619
Practice Address - Fax:228-896-8619
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS482152W00000X, 332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087901Medicaid
MS560948114Medicare ID - Type Unspecified
MS00087901Medicaid