Healthcare Provider Details

I. General information

NPI: 1578950879
Provider Name (Legal Business Name): DR. MARRA, OPTOMETRIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5834 MONROE ST STE D
SYLVANIA OH
43560-2265
US

IV. Provider business mailing address

5834 MONROE ST STE D
SYLVANIA OH
43560-2265
US

V. Phone/Fax

Practice location:
  • Phone: 419-475-6605
  • Fax: 419-475-2017
Mailing address:
  • Phone: 419-475-6605
  • Fax: 419-475-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4212
License Number StateOH

VIII. Authorized Official

Name: JOSEPH T. MARRA
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 419-475-6605