Provider Demographics
NPI:1366656894
Name:MARCUS, CARL R (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:R
Last Name:MARCUS
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:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-0232
Mailing Address - Country:US
Mailing Address - Phone:253-735-6548
Mailing Address - Fax:253-735-6548
Practice Address - Street 1:36216 57TH AVE S
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-9307
Practice Address - Country:US
Practice Address - Phone:253-735-6548
Practice Address - Fax:253-735-6548
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000853152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA93422275060001OtherPREMERA BLUE CROSS NATACT
WAWA0514OtherNORTHWEST BENEFIT NETWORK
WAMA0876OtherREGENCE BLUE SHIELD
WA2567402Medicaid
WA911348OtherEYEMED
WA227506100000OtherPREMERA BLUE CROSS
WAWA0514OtherNORTHWEST BENEFIT NETWORK
WA2567402Medicaid