Healthcare Provider Details

I. General information

NPI: 1912995739
Provider Name (Legal Business Name): GERALD MARSH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5852 MAYFIELD RD
MAYFIELD HEIGHTS OH
44124-2903
US

IV. Provider business mailing address

5852 MAYFIELD RD
MAYFIELD HEIGHTS OH
44124-2903
US

V. Phone/Fax

Practice location:
  • Phone: 440-684-0800
  • Fax:
Mailing address:
  • Phone: 440-684-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2500/T549
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: