Provider Demographics
NPI:1629628292
Name:REIDY, MARIELLE GRACE (OD, MS)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:GRACE
Last Name:REIDY
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:MARIELLE
Other - Middle Name:GRACE
Other - Last Name:BLUMENTHALER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD, MS
Mailing Address - Street 1:5460 E LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-2023
Mailing Address - Country:US
Mailing Address - Phone:714-463-7500
Mailing Address - Fax:714-992-7850
Practice Address - Street 1:1664 NEIL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-2333
Practice Address - Country:US
Practice Address - Phone:614-292-2020
Practice Address - Fax:614-247-6626
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34402152W00000X
OHOPT.006732152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist