Provider Demographics
NPI:1205887932
Name:MARION, STEPHEN RANDALL (OD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RANDALL
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 1:1100 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1374
Mailing Address - Country:US
Mailing Address - Phone:920-563-8468
Mailing Address - Fax:920-563-0178
Practice Address - Street 1:1100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1374
Practice Address - Country:US
Practice Address - Phone:920-563-8468
Practice Address - Fax:920-563-0178
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1417-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMARIOSRAOtherMERCYCARE
WI2149813OtherUNITED HEALTHCARE
WI1560OtherDEAN HEALTH INSURANCE
WI1006590OtherPHYSICIANS PLUS
WI38572400Medicaid
WI2149813OtherUNITED HEALTHCARE
T62680Medicare UPIN
WI000347795Medicare PIN