Provider Demographics
NPI:1396841979
Name:MAROTTA, SANDRA KAY (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:KAY
Last Name:MAROTTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13029 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2001
Mailing Address - Country:US
Mailing Address - Phone:703-322-2020
Mailing Address - Fax:703-322-1221
Practice Address - Street 1:13029 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2001
Practice Address - Country:US
Practice Address - Phone:703-322-2020
Practice Address - Fax:703-322-1221
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5671134OtherAETNA
411854OtherOCI MOMS
541660280OtherCIGNA
VAVA1534OtherEYEMED
411854OtherOCI MOMS
U56797Medicare UPIN