Provider Demographics
NPI:1881001626
Name:HOLDERBY, MARI SHELLY (OD)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:SHELLY
Last Name:HOLDERBY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:321-221-2047
Practice Address - Street 1:7912 FOREST CITY RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-2907
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:321-221-2047
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012769900Medicaid