Provider Demographics
NPI:1669621553
Name:KOONTZ, MARCIE LYN (OD)
Entity type:Individual
Prefix:DR
First Name:MARCIE
Middle Name:LYN
Last Name:KOONTZ
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 1:333 W. TRADE ST.
Mailing Address - Street 2:APT. 1201
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-1970
Mailing Address - Country:US
Mailing Address - Phone:814-442-0437
Mailing Address - Fax:
Practice Address - Street 1:2406 W ROOSEVELT BLVD
Practice Address - Street 2:THE VISION CENTER
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8430
Practice Address - Country:US
Practice Address - Phone:704-588-8609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4332152W00000X
NC2117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist