Provider Demographics
NPI:1578565537
Name:ZAMORA, MARSHALL W (OD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:W
Last Name:ZAMORA
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:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47282-0576
Mailing Address - Country:US
Mailing Address - Phone:812-521-2002
Mailing Address - Fax:
Practice Address - Street 1:210 W MAIN CROSS ST
Practice Address - Street 2:
Practice Address - City:EDINBURGH
Practice Address - State:IN
Practice Address - Zip Code:46124-1390
Practice Address - Country:US
Practice Address - Phone:812-526-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INP00107057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000308885OtherANTHEM
IN200453530Medicaid
IN160660CMedicare ID - Type Unspecified
INU96651Medicare UPIN
IN0430000001Medicare NSC