Provider Demographics
NPI:1679087290
Name:MARIN EYE CARE
Entity Type:Organization
Organization Name:MARIN EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOZAYANI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:415-883-9888
Mailing Address - Street 1:440 IGNACIO BLVD
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6085
Mailing Address - Country:US
Mailing Address - Phone:415-883-9888
Mailing Address - Fax:415-883-1159
Practice Address - Street 1:440 IGNACIO BLVD
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6085
Practice Address - Country:US
Practice Address - Phone:415-883-9888
Practice Address - Fax:415-883-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9545T152W00000X
CA13793T152W00000X
CA15419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417967225OtherBLUE SHIELD