Provider Demographics
NPI:1861801177
Name:HUANG, MARISSA (OD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HUANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 JACOB CT
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 GRANT AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3167
Practice Address - Country:US
Practice Address - Phone:415-898-2320
Practice Address - Fax:415-892-7000
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008153-1152W00000X
CA15444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist