Provider Demographics
NPI: | 1578950879 |
---|---|
Name: | DR. MARRA, OPTOMETRIST, LLC |
Entity Type: | Organization |
Organization Name: | DR. MARRA, OPTOMETRIST, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/OPTOMETRIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOSEPH |
Authorized Official - Middle Name: | T |
Authorized Official - Last Name: | MARRA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OD |
Authorized Official - Phone: | 419-475-6605 |
Mailing Address - Street 1: | 4240 SECOR RD |
Mailing Address - Street 2: | |
Mailing Address - City: | TOLEDO |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43623-4238 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 419-475-6605 |
Mailing Address - Fax: | 419-475-2017 |
Practice Address - Street 1: | 4240 SECOR RD |
Practice Address - Street 2: | |
Practice Address - City: | TOLEDO |
Practice Address - State: | OH |
Practice Address - Zip Code: | 43623-4238 |
Practice Address - Country: | US |
Practice Address - Phone: | 419-475-6605 |
Practice Address - Fax: | 419-475-2017 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-04-24 |
Last Update Date: | 2015-04-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 4212 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Single Specialty |