Healthcare Provider Details

I. General information

NPI: 1578565537
Provider Name (Legal Business Name): MARSHALL W ZAMORA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MAIN CROSS ST
EDINBURGH IN
46124-1390
US

IV. Provider business mailing address

PO BOX 576
VERNON IN
47282-0576
US

V. Phone/Fax

Practice location:
  • Phone: 812-526-2020
  • Fax:
Mailing address:
  • Phone: 812-521-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberP00107057
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: