Provider Demographics
NPI:1568630770
Name:NEILL R MARSHALL OD PC
Entity Type:Organization
Organization Name:NEILL R MARSHALL OD PC
Other - Org Name:OPTOMETRIST
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-455-4300
Mailing Address - Street 1:903 THIRD STREET
Mailing Address - Street 2:PO BOX 219
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155
Mailing Address - Country:US
Mailing Address - Phone:304-455-4300
Mailing Address - Fax:304-455-4306
Practice Address - Street 1:903 THIRD STREET
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155
Practice Address - Country:US
Practice Address - Phone:304-455-4300
Practice Address - Fax:304-455-4306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV586OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0364090001Medicare NSC
MA9129321Medicare PIN
WVT32512Medicare UPIN