Healthcare Provider Details

I. General information

NPI: 1275730343
Provider Name (Legal Business Name): JOHN J MARIA OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2007
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 DONELSON PKWY
DOVER TN
37058-3753
US

IV. Provider business mailing address

PO BOX 423
DOVER TN
37058-0423
US

V. Phone/Fax

Practice location:
  • Phone: 931-232-5118
  • Fax: 931-232-0581
Mailing address:
  • Phone: 931-232-5118
  • Fax: 931-232-0581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1471
License Number StateTN

VIII. Authorized Official

Name: DR. JOHN MARIA
Title or Position: OWNER
Credential: O.D.
Phone: 931-232-5118