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General NPI Number Information
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NPI Number | 1770256042
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Entity Type | Individual
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Provider Name | MARISSA VELASCO JIMENEZ
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Gender | Female
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Dates
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Enumeration Date | 07/31/2021
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Last Update Date | 10/04/2021
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Provider Practice Location Address
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Address Line | 3200 S UNIVERSITY DR
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City | DAVIE
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State | FL
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Zip | 33328-2018
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Country | US
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Telephone | 954-262-4200
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Fax |
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Provider Business Mailing Address
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Address Line | 7006 SNOWY OWL ST
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City | ARLINGTON
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State | TX
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Zip | 76002-3378
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Country | US
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Telephone |
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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 | 10374
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPFC101
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License Number State | FL
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