Healthcare Provider Details

I. General information

NPI: 1235491820
Provider Name (Legal Business Name): MITCHELL J MARDER P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4923 COCONUT CREEK PKWY
COCONUT CREEK FL
33063-3909
US

IV. Provider business mailing address

11368 ISLAND LAKES LN
BOCA RATON FL
33498-6805
US

V. Phone/Fax

Practice location:
  • Phone: 954-970-4266
  • Fax:
Mailing address:
  • Phone: 561-445-3086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC001674
License Number StateFL

VIII. Authorized Official

Name: DR. MITCHELL J MARDER
Title or Position: PRESIDENT
Credential: O.D.
Phone: 561-445-3086