Provider Demographics
NPI:1407921851
Name:MARASON, RICHARD (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MARASON
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 1:600 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3714
Mailing Address - Country:US
Mailing Address - Phone:530-257-3636
Mailing Address - Fax:530-257-7194
Practice Address - Street 1:600 ASH ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3714
Practice Address - Country:US
Practice Address - Phone:530-257-3636
Practice Address - Fax:530-257-7194
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0090400Medicaid
CAT90349Medicare UPIN
CASD0090400Medicare PIN
CA0664630001Medicare NSC