Provider Demographics
NPI:1720243850
Name:SERENDA, MARIELLE B (OD)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:B
Last Name:SERENDA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:623 E BOUGHTON RD
Practice Address - Street 2:STE 120
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2498
Practice Address - Country:US
Practice Address - Phone:630-783-1514
Practice Address - Fax:630-783-0654
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL04601029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist