Provider Demographics
NPI:1750485314
Name:MARIN, JOSE JR (OD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:MARIN
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 1:901 N BRUTSCHER ST STE E
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132
Mailing Address - Country:US
Mailing Address - Phone:803-554-5555
Mailing Address - Fax:503-538-1896
Practice Address - Street 1:901 N BRUTSCHER ST STE E
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132
Practice Address - Country:US
Practice Address - Phone:803-554-5555
Practice Address - Fax:503-538-1896
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2591ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150665Medicaid
R100780Medicare ID - Type Unspecified
U67843Medicare UPIN