Provider Demographics
NPI:1669467189
Name:MARCIN, JOSEPH T JR (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:T
Last Name:MARCIN
Suffix:JR
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 1:1401 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-1256
Mailing Address - Country:US
Mailing Address - Phone:217-774-2181
Mailing Address - Fax:217-774-3104
Practice Address - Street 1:1401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-1256
Practice Address - Country:US
Practice Address - Phone:217-774-2181
Practice Address - Fax:217-774-3104
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047027210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410024289Medicare PIN
672431Medicare ID - Type Unspecified
T37704Medicare UPIN
IL0735740002Medicare NSC
IL672430Medicare PIN
IL410006290Medicare PIN