Healthcare Provider Details

I. General information

NPI: 1114114592
Provider Name (Legal Business Name): THOMAS JAY MARQUARDT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 NORTH THIRD STREET
GRANBY CO
80446-0090
US

IV. Provider business mailing address

PO BOX 90
GRANBY CO
80446-0090
US

V. Phone/Fax

Practice location:
  • Phone: 970-887-2459
  • Fax:
Mailing address:
  • Phone: 970-887-2459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPTOMETRY902
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: