MEDICARE: JOHN B. MARSHALL OPTOMETRIST PA

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
1	152W00000X	Optometrist		NC
2	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	152W00000X	OTHER	NC	TAXONOMY NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1296470001	OTHER	NC	PTAN

General Provider Information

NPI Number	:	1659594224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN B. MARSHALL OPTOMETRIST PA

Provider Business Mailing Address
First Line	:	320 S CHURTON ST
Second Line	:
City	:	HILLSBOROUGH
State	:	NC
Zip	:	27278-2509
Country	:	US
Telephone Number	:	919-732-5000
Fax Number	:	919-732-6855

Provider Business Practice Location Address
First Line	:	320 S CHURTON ST
Second Line	:
City	:	HILLSBOROUGH
State	:	NC
Zip	:	27278-2509
Country	:	US
Telephone Number	:	919-732-5000
Fax Number	:	919-732-6855

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN BRYAN MARSHALL
Credential	:	O.D.
Telephone Number	:	919-732-5000

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	01/15/2013

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