Healthcare Provider Details

I. General information

NPI: 1508086166
Provider Name (Legal Business Name): MARLIN B NEIL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12312 OLIVE BLVD STE 150
SAINT LOUIS MO
63141-5468
US

IV. Provider business mailing address

7079 POST COACH DR
O FALLON MO
63368-6017
US

V. Phone/Fax

Practice location:
  • Phone: 314-336-9090
  • Fax:
Mailing address:
  • Phone: 636-978-5112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberTO2930
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: