Provider Demographics
NPI:1295782415
Name:MARVIN-MANDERS, JULIE A (OD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:A
Last Name:MARVIN-MANDERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 PENTECOST HWY
Mailing Address - Street 2:
Mailing Address - City:ONSTED
Mailing Address - State:MI
Mailing Address - Zip Code:49265-9604
Mailing Address - Country:US
Mailing Address - Phone:734-260-5160
Mailing Address - Fax:
Practice Address - Street 1:110 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48158-9776
Practice Address - Country:US
Practice Address - Phone:734-428-2020
Practice Address - Fax:734-428-8955
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH16788001OtherMEDICARE PTAN, INDIVIDUAL
MIH16788001OtherMEDICARE PTAN, INDIVIDUAL