Provider Demographics
NPI:1952488397
Name:MARION, DONALD R (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:MARION
Suffix:
Gender:M
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:PO BOX 369
Mailing Address - Street 2:2 PARK AVENUE WEST
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356
Mailing Address - Country:US
Mailing Address - Phone:815-879-2020
Mailing Address - Fax:815-879-2001
Practice Address - Street 1:2 PARK AVENUE WEST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356
Practice Address - Country:US
Practice Address - Phone:815-879-2020
Practice Address - Fax:815-879-2001
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL684000OtherBCBS
IL448140Medicare ID - Type Unspecified
IL684000OtherBCBS
410027035Medicare ID - Type UnspecifiedRAILROAD
0342400001Medicare NSC