Provider Demographics
NPI:1740590801
Name:MARUM, EDWARD STUART
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:STUART
Last Name:MARUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-3143
Mailing Address - Country:US
Mailing Address - Phone:516-317-5516
Mailing Address - Fax:718-747-6442
Practice Address - Street 1:15012 14TH AVE
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1800
Practice Address - Country:US
Practice Address - Phone:718-746-3937
Practice Address - Fax:718-747-6442
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5672-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician