Healthcare Provider Details

I. General information

NPI: 1023134665
Provider Name (Legal Business Name): LOUIS JOHN MARINO OCULARIST OCULAR PRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N COLONY ST
WALLINGFORD CT
06492-3656
US

IV. Provider business mailing address

204 N COLONY ST
WALLINGFORD CT
06492-3656
US

V. Phone/Fax

Practice location:
  • Phone: 203-284-3737
  • Fax: 203-284-1300
Mailing address:
  • Phone: 203-284-3737
  • Fax: 203-284-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number0315275000
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: