Healthcare Provider Details

I. General information

NPI: 1568774628
Provider Name (Legal Business Name): JUSTIN MARSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CONCOURSE PKWY S STE 200
MAITLAND FL
32751-6114
US

IV. Provider business mailing address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-6411
  • Fax:
Mailing address:
  • Phone: 816-234-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number04-38026
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2015014708
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME143292
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: