Provider Demographics
NPI:1730140328
Name:MARSHALECK, EDWARD THOMAS (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:THOMAS
Last Name:MARSHALECK
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:PO BOX 7203
Mailing Address - Street 2:
Mailing Address - City:PENNDEL
Mailing Address - State:PA
Mailing Address - Zip Code:19047-7203
Mailing Address - Country:US
Mailing Address - Phone:215-752-3252
Mailing Address - Fax:215-752-3252
Practice Address - Street 1:132 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:PENNDEL
Practice Address - State:PA
Practice Address - Zip Code:19047-5256
Practice Address - Country:US
Practice Address - Phone:215-752-3252
Practice Address - Fax:215-752-3252
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0546740Medicaid
PAU06348Medicare UPIN
PA0546740Medicaid
PA0156050001Medicare NSC