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NPI Code Detail

MEDICARE: MARISSA ALDRICH O.D.

MEDICARE: MARISSA ALDRICH O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist8539TTX
2152W00000XOptometrist091381IA
3152W00000XOptometrist3447ATIOR
4152W00000XOptometristOD60293969WA
5152W00000XOptometrist046011389IL
6152W00000XOptometrist2687NC

General Provider Information

NPI Number : 1629304191
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARISSA ALDRICH O.D.
Provider Business Mailing Address
First Line : PO BOX 207261
Second Line :
City : DALLAS
State : TX
Zip : 75320-7261
Country : US
Telephone Number : 636-200-4393
Fax Number : 636-527-0766
Provider Business Practice Location Address
First Line : 3500 W PETERSON AVE STE 401
Second Line :
City : CHICAGO
State : IL
Zip : 60659-3307
Country : US
Telephone Number : 773-588-3090
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/19/2009
Last Update Date : 06/21/2022

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