Provider Demographics
NPI:1457584328
Name:WARDELL, MARIAN VICTORIA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:VICTORIA
Last Name:WARDELL
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 1:22009 SHORE POINTE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3576
Mailing Address - Country:US
Mailing Address - Phone:772-233-5959
Mailing Address - Fax:
Practice Address - Street 1:3601 WASHTENAW AVE
Practice Address - Street 2:SUITE E
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5277
Practice Address - Country:US
Practice Address - Phone:734-973-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004548152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist