Provider Demographics
NPI:1336216563
Name:NEILL, MARVIN WESLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:WESLEY
Last Name:NEILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MARVIN
Other - Middle Name:W
Other - Last Name:NEILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:9201 BIG HORN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9201 BIG HORN BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-1240
Practice Address - Country:US
Practice Address - Phone:916-478-5580
Practice Address - Fax:916-478-5578
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5188 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist