1154353944 NPI number — DR. TRACEY MARSHALL-UNDERWOOD O.D.

Table of content: DR. TRACEY MARSHALL-UNDERWOOD O.D. (NPI 1154353944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154353944 NPI number — DR. TRACEY MARSHALL-UNDERWOOD O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL-UNDERWOOD
Provider First Name:
TRACEY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1154353944
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 YARMOUTH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19904-5392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-734-5861
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 WOLF CREEK BLVD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19901-4915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-678-3932
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2006

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:  I3-0001312 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com