Provider Demographics
NPI:1023134665
Name:MARINO, LOUIS JOHN (OCULARIST OCULAR PRO)
Entity type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:JOHN
Last Name:MARINO
Suffix:
Gender:M
Credentials:OCULARIST OCULAR PRO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N COLONY ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3656
Mailing Address - Country:US
Mailing Address - Phone:203-284-3737
Mailing Address - Fax:203-284-1300
Practice Address - Street 1:204 N COLONY ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3656
Practice Address - Country:US
Practice Address - Phone:203-284-3737
Practice Address - Fax:203-284-1300
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0315275000156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12DME0303CT01OtherANTHEM BLUE CROSS AND BLU
CT004092201Medicaid
CT12DME0303CT01OtherANTHEM BLUE CROSS AND BLU