Provider Demographics
NPI:1912057118
Name:MARSHALL FAMILY EYECARE
Entity Type:Organization
Organization Name:MARSHALL FAMILY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRUSTEE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-448-2233
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:AR
Mailing Address - Zip Code:72650-1109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 E. MAIN
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:AR
Practice Address - Zip Code:72650
Practice Address - Country:US
Practice Address - Phone:870-448-2233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C391Medicare ID - Type Unspecified
AR48642Medicare UPIN