Provider Demographics
NPI:1942310370
Name:NICKERSON, MARITZA MARQUEZ (OD)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:MARQUEZ
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARITZA
Other - Middle Name:
Other - Last Name:MARQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15349
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-5349
Mailing Address - Country:US
Mailing Address - Phone:850-383-3322
Mailing Address - Fax:
Practice Address - Street 1:1491 GOVERNORS SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3049
Practice Address - Country:US
Practice Address - Phone:850-383-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4042152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist