Provider Demographics
NPI:1407917891
Name:MARIONNEAUX, WILLARD E JR (OD)
Entity Type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:E
Last Name:MARIONNEAUX
Suffix:JR
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 910
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295
Mailing Address - Country:US
Mailing Address - Phone:318-435-5145
Mailing Address - Fax:318-435-9476
Practice Address - Street 1:6609 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295
Practice Address - Country:US
Practice Address - Phone:318-435-5145
Practice Address - Fax:318-435-9476
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA712014T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1117307Medicaid
5388880001OtherPALMETTO
LA1117307Medicaid
5388880001OtherPALMETTO