Provider Demographics
NPI:1497783203
Name:SHEPARD-MARZIALE, LYNDA JEAN (OD)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:JEAN
Last Name:SHEPARD-MARZIALE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LYNDA
Other - Middle Name:JEAN
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:100 PROVIDENCE PLACE
Mailing Address - Street 2:
Mailing Address - City:CHOCOWINITY
Mailing Address - State:NC
Mailing Address - Zip Code:27817
Mailing Address - Country:US
Mailing Address - Phone:828-384-0377
Mailing Address - Fax:
Practice Address - Street 1:4600 E 10TH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-0849
Practice Address - Country:US
Practice Address - Phone:252-329-7025
Practice Address - Fax:252-329-7025
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0917POtherBLUE CROSS BLUE SHIELD NC
17552OtherSPECTERA
2200131OtherUNITED HEALTHCARE
NC890917PMedicaid
6952803OtherCIGNA
0917POtherBLUE CROSS BLUE SHIELD NC