Provider Demographics
NPI:1326097601
Name:MARINO, MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARINO
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 1:113 SALEM TOWNE CT
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-2311
Mailing Address - Country:US
Mailing Address - Phone:919-367-8411
Mailing Address - Fax:919-367-8431
Practice Address - Street 1:113 SALEM TOWNE CT
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-2311
Practice Address - Country:US
Practice Address - Phone:919-367-8411
Practice Address - Fax:919-367-8431
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1716152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890908CMedicaid
NC890908CMedicaid
NCU72404Medicare UPIN