Healthcare Provider Details

I. General information

NPI: 1447220470
Provider Name (Legal Business Name): PAUL ALLEN MARNUL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S STATE ST
MARENGO IL
60152-2229
US

IV. Provider business mailing address

211 S STATE ST
MARENGO IL
60152-2229
US

V. Phone/Fax

Practice location:
  • Phone: 815-568-3937
  • Fax:
Mailing address:
  • Phone: 815-568-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0467574
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT006884-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: