Provider Demographics
NPI:1790965101
Name:MAR, ELLVIN JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLVIN
Middle Name:JOHN
Last Name:MAR
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:834 FORT SALONGA RD STE D
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3157
Mailing Address - Country:US
Mailing Address - Phone:631-757-4440
Mailing Address - Fax:631-757-4593
Practice Address - Street 1:834 FORT SALONGA RD STE D
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3157
Practice Address - Country:US
Practice Address - Phone:631-757-4440
Practice Address - Fax:631-757-4593
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY007221152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist