Provider Demographics
NPI:1932190055
Name:LINNELL, MARY ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:LINNELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:NAVAL HOSPITAL BEAUFORT
Mailing Address - Street 2:1 PINCKNEY BLVD.
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902
Mailing Address - Country:US
Mailing Address - Phone:843-228-1342
Mailing Address - Fax:
Practice Address - Street 1:670 BOULEVARD DE FRANCE
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29905
Practice Address - Country:US
Practice Address - Phone:843-228-1342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002666152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN