Healthcare Provider Details

I. General information

NPI: 1306926068
Provider Name (Legal Business Name): RUSSELL A MARINGER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 W WATER ST STE L
OAK HARBOR OH
43449-1373
US

IV. Provider business mailing address

3972 S MEMORIAL SHOREWAY DR EYE SURGERY CONSULTANTS INC.
LAKESIDE MARBLEHEAD OH
43440-2374
US

V. Phone/Fax

Practice location:
  • Phone: 419-898-1918
  • Fax: 866-651-8467
Mailing address:
  • Phone: 567-230-0263
  • Fax: 866-651-8467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5494
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number5494/T2406
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: