MEDICARE: MARI SHELLY HOLDERBY 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
1	152W00000X	Optometrist	OPC4915	FL

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

General Provider Information

NPI Number	:	1881001626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARI SHELLY HOLDERBY O.D.

Provider Business Mailing Address
First Line	:	110 S WOODLAND ST
Second Line	:
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-3546
Country	:	US
Telephone Number	:	407-905-8827
Fax Number	:	321-221-2047

Provider Business Practice Location Address
First Line	:	7912 FOREST CITY RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32810-2907
Country	:	US
Telephone Number	:	407-905-8827
Fax Number	:	321-221-2047

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2014
Last Update Date	:	04/28/2016

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