Provider Demographics
NPI:1063504439
Name:MARIN, EDISON (OD)
Entity type:Individual
Prefix:DR
First Name:EDISON
Middle Name:
Last Name:MARIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 361493
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-1493
Mailing Address - Country:US
Mailing Address - Phone:787-276-3435
Mailing Address - Fax:787-276-4835
Practice Address - Street 1:5829 AVE 65 INFANTERIA STE 105
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00987-5008
Practice Address - Country:US
Practice Address - Phone:787-276-3435
Practice Address - Fax:787-276-4835
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRP313Medicare UPIN
PR31355Medicare UPIN
PR215092Medicare UPIN
PR50083Medicare ID - Type UnspecifiedTRIPLE-S
PR100011Medicare UPIN
PR890280Medicare UPIN
PR00079Medicare UPIN
PR9870008Medicare UPIN