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General NPI Number Information
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NPI Number | 1508122854
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Entity Type | Organization
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Legal Business Name | MARY M FUTCH OD PA
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Dates
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Enumeration Date | 04/11/2012
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Last Update Date | 08/06/2012
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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 | 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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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARY MARTHA FUTCH
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Credential | OD
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Telephone | 904-259-6259
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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 | OPC 2517
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License Number State | FL
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