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General NPI Number Information
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NPI Number | 1356361208
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Entity Type | Individual
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Provider Name | MARY MARTHA FUTCH O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 31 S 6TH ST
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City | MACCLENNY
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State | FL
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Zip | 32063-2311
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Country | US
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Telephone | 904-259-6259
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Fax | 904-259-3436
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Provider Business Mailing Address
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Address Line | 9863 OLD PLANK RD
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City | JACKSONVILLE
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State | FL
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Zip | 32220-1335
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Country | US
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Telephone | 904-783-8613
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2517
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License Number State | FL
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