=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720391675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATISHA MARBUARY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2010
-----------------------------------------------------
Last Update Date | 01/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1737 DRIFTWOOD LN
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35235-2981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-370-9430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5865 WATER POINT LN
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35244-4115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-370-9430
-----------------------------------------------------
Fax | 256-233-2309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | SC-44-TA-870
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------