Provider Demographics
NPI:1639171010
Name:MARIETTA OPHTHALMOLOGY ASSOCIATES INC
Entity Type:Organization
Organization Name:MARIETTA OPHTHALMOLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-373-8046
Mailing Address - Street 1:210 N 7TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2244
Mailing Address - Country:US
Mailing Address - Phone:740-373-8046
Mailing Address - Fax:740-373-0182
Practice Address - Street 1:210 N SEVENTH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2244
Practice Address - Country:US
Practice Address - Phone:740-373-8046
Practice Address - Fax:740-373-0182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH55641207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0095420000Medicaid
OH0672106Medicaid
WV0095420000Medicaid
WV1099330001Medicare NSC
OH9282721Medicare PIN