Provider Demographics
NPI:1326122680
Name:MARSHALL, GABRIELLE WARREN (OD)
Entity Type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:WARREN
Last Name:MARSHALL
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 1:2463 NW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1246
Mailing Address - Country:US
Mailing Address - Phone:541-382-0671
Mailing Address - Fax:
Practice Address - Street 1:2736 NW CROSSING DR
Practice Address - Street 2:SUITE 120
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-323-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2635 ATI152W00000X
OR2635ATI152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU67842Medicare UPIN