1629060751 NPI number — MARC H SHERMAN OD, PA

Table of content: MARC H SHERMAN OD, PA (NPI 1629060751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629060751 NPI number — MARC H SHERMAN OD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERMAN
Provider First Name:
MARC
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD, PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629060751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1495 W STATE ROAD 434
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
LONGWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32750-3847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-332-8255
Provider Business Mailing Address Fax Number:
407-332-5769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1495 W STATE ROAD 434
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
LONGWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32750-3847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-332-8255
Provider Business Practice Location Address Fax Number:
407-332-5769
Provider Enumeration Date:
08/16/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC1051 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152WV0400X , with the licence number: OPC1051 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 084456000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: D04539 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".