Healthcare Provider Details

I. General information

NPI: 1457432239
Provider Name (Legal Business Name): CARL J MARASCALCO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 OLD HICKORY RD
GRENADA MS
38901-2727
US

IV. Provider business mailing address

600 OLD HICKORY RD
GRENADA MS
38901-2727
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-7010
  • Fax: 662-226-7027
Mailing address:
  • Phone: 662-226-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number504
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: