Provider Demographics
NPI:1639214679
Name:MAR, VICTORIA L (OD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:MAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 S DURANGO DR STE A110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3606
Mailing Address - Country:US
Mailing Address - Phone:702-736-8883
Mailing Address - Fax:702-877-8882
Practice Address - Street 1:7415 S DURANGO DR STE A110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-3606
Practice Address - Country:US
Practice Address - Phone:702-736-8883
Practice Address - Fax:702-877-8882
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100168Medicare ID - Type Unspecified
CAU12104Medicare UPIN