Healthcare Provider Details

I. General information

NPI: 1124060629
Provider Name (Legal Business Name): MARION D WESTON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W SPRING ST
NEOSHO MO
64850-1720
US

IV. Provider business mailing address

1531 W 32ND ST STE 102
JOPLIN MO
64804-1611
US

V. Phone/Fax

Practice location:
  • Phone: 417-451-0400
  • Fax: 417-781-9814
Mailing address:
  • Phone: 417-781-3630
  • Fax: 417-624-9704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02157
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: