Provider Demographics
NPI:1679678809
Name:ACQUISTAPACE, MARVIN R (OD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:R
Last Name:ACQUISTAPACE
Suffix:
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 1:750 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-2638
Mailing Address - Country:US
Mailing Address - Phone:907-978-2734
Mailing Address - Fax:
Practice Address - Street 1:116 MINNIE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3006
Practice Address - Country:US
Practice Address - Phone:907-456-7760
Practice Address - Fax:907-451-7916
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD0014Medicaid
AK1023203Medicaid
AKK162855Medicare PIN