Provider Demographics
NPI:1649321225
Name:MARINKOVICH, ANDREW R JR (OD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:MARINKOVICH
Suffix:JR
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 1:5525 MOONSHADOW ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-5740
Mailing Address - Country:US
Mailing Address - Phone:805-415-1919
Mailing Address - Fax:818-981-9702
Practice Address - Street 1:518 N MOORPARK RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3703
Practice Address - Country:US
Practice Address - Phone:805-373-0599
Practice Address - Fax:805-495-4263
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU44135Medicare UPIN
CAWOP8797Medicare ID - Type Unspecified