Provider Demographics
NPI:1962441220
Name:MUNCH, MARSHALL VERNON (OD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:VERNON
Last Name:MUNCH
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 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4038
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:175 SHINN LN
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401
Practice Address - Country:US
Practice Address - Phone:573-248-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3361152WC0802X
MOT03361152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO134570018OtherMEDICARE PTAN FOR QMG
MO318910718Medicaid
MO410045181OtherRAILROAD MEDICARE
MO990000642OtherMEDICARE GROUP
MOCI3223OtherRAILROAD MEDICARE GROUP
MO1245285543OtherMEDICARE GROUP NPI
MO000091251Medicare PIN
MO318910718Medicaid
MOU68125Medicare UPIN