Provider Demographics
NPI:1245325133
Name:MARDER, MITCHELL J (OD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:J
Last Name:MARDER
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 1:11368 ISLAND LKS LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6805
Mailing Address - Country:US
Mailing Address - Phone:561-451-8115
Mailing Address - Fax:
Practice Address - Street 1:4923 COCONUT CREEK PKWY
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33063
Practice Address - Country:US
Practice Address - Phone:954-970-4266
Practice Address - Fax:954-975-0416
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1674152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078199100Medicaid
FL19873Medicare ID - Type Unspecified
FL078199100Medicaid