Provider Demographics
NPI:1477548220
Name:MARSHALL, DENNIS N (OD, PA)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:N
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:OD, PA
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 40
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0040
Mailing Address - Country:US
Mailing Address - Phone:208-785-3063
Mailing Address - Fax:208-782-1392
Practice Address - Street 1:1495 PARKWAY DR STE A
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1639
Practice Address - Country:US
Practice Address - Phone:208-785-3063
Practice Address - Fax:208-782-1392
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001261500Medicaid
ID5827770001Medicare NSC
ID001261500Medicaid
ID15913341Medicare PIN