Provider Demographics
NPI:1922037654
Name:MARBOURG, ROBIN LIVELY (OD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:LIVELY
Last Name:MARBOURG
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 1:5170 TRACE CROSSINGS DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3954
Mailing Address - Country:US
Mailing Address - Phone:205-985-9484
Mailing Address - Fax:205-985-9371
Practice Address - Street 1:308 6TH ST S
Practice Address - Street 2:SUITE 105
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-1846
Practice Address - Country:US
Practice Address - Phone:205-625-5520
Practice Address - Fax:205-625-5522
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-712-TA-055152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL76603OtherUMWA
ALU18675OtherVIVA
AL009938093Medicaid
AL000076603Medicaid
ALU18675OtherHEALTH SPRINGS
AL510-76603OtherBLUE CROSS & BLUE SHIELD
AL515-36833OtherBLUE CROSS & BLUE SHIELD
AL924809OtherBLOCK VISION
AL924809OtherBLOCK VISION
AL510-76603OtherBLUE CROSS & BLUE SHIELD
ALU18675Medicare UPIN