Provider Demographics
NPI:1528250180
Name:DENNIS N. MARSHALL, O.D., P.A.
Entity type:Organization
Organization Name:DENNIS N. MARSHALL, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:N
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PA
Authorized Official - Phone:208-785-3063
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0040
Mailing Address - Country:US
Mailing Address - Phone:208-785-3063
Mailing Address - Fax:208-782-1392
Practice Address - Street 1:1495 PARKWAY DR STE A
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1639
Practice Address - Country:US
Practice Address - Phone:208-785-3063
Practice Address - Fax:208-782-1392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001261500Medicaid
ID1370042Medicare PIN
ID001261500Medicaid
IDT44340Medicare UPIN