Provider Demographics
NPI:1902884489
Name:MARSH, JEFFREY J (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
Last Name:MARSH
Suffix:
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 1:423 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901
Mailing Address - Country:US
Mailing Address - Phone:920-426-2020
Mailing Address - Fax:920-235-3195
Practice Address - Street 1:423 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901
Practice Address - Country:US
Practice Address - Phone:920-426-2020
Practice Address - Fax:920-235-3195
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38529700Medicaid
T86524Medicare UPIN
WI38529700Medicaid