Healthcare Provider Details

I. General information

NPI: 1720391675
Provider Name (Legal Business Name): LATISHA MARBUARY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 DRIFTWOOD LN
BIRMINGHAM AL
35235-2981
US

IV. Provider business mailing address

5865 WATER POINT LN
HOOVER AL
35244-4115
US

V. Phone/Fax

Practice location:
  • Phone: 205-370-9430
  • Fax:
Mailing address:
  • Phone: 256-370-9430
  • Fax: 256-233-2309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberSC-44-TA-870
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: