Healthcare Provider Details

I. General information

NPI: 1528064656
Provider Name (Legal Business Name): MARK THOMAS MARCIANO O D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1788 N. JOG RD.
WEST PALM BEACH FL
33411-0000
US

IV. Provider business mailing address

1788 N. JOG RD.
WEST PALM BEACH FL
33411-0000
US

V. Phone/Fax

Practice location:
  • Phone: 561-242-1200
  • Fax: 561-242-1291
Mailing address:
  • Phone: 561-242-1200
  • Fax: 561-242-1291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP3248
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: