Provider Demographics
NPI:1508814070
Name:MARSHALL, TINA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:LANDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17370 PRESTON RD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5998
Mailing Address - Country:US
Mailing Address - Phone:972-520-2020
Mailing Address - Fax:972-239-0840
Practice Address - Street 1:17370 PRESTON RD
Practice Address - Street 2:SUITE 410
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5998
Practice Address - Country:US
Practice Address - Phone:972-520-2020
Practice Address - Fax:972-239-0840
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2603152W00000X
FL3911152W00000X
TX7187TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT090002603CT01OtherANTHEM BC/BS
CT1282160002OtherMEDICARE DME
CT16201OtherSPECTERA
CT2995970OtherAETNA
CTP2739088OtherOXFORD
CT260300OtherCONNECTICARE
CT2V2616OtherHEALTHNET
CT2034688800OtherVISION SERVICE PLAN
CT2915525OtherCIGNA
CT2995970OtherAETNA
CT410001062Medicare ID - Type Unspecified