Provider Demographics
NPI:1104972116
Name:MARSHALL, JOHN BRYAN (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BRYAN
Last Name:MARSHALL
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 1:11312 US 15-501 NORTH
Mailing Address - Street 2:STE. 304
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-6376
Mailing Address - Country:US
Mailing Address - Phone:919-933-6767
Mailing Address - Fax:919-933-6732
Practice Address - Street 1:11312 US 15-501 NORTH
Practice Address - Street 2:STE. 304
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-6376
Practice Address - Country:US
Practice Address - Phone:919-933-6767
Practice Address - Fax:919-933-6732
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1551152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909104Medicaid
NCU54004Medicare UPIN
2469555DMedicare PIN
NCU54004Medicare UPIN
NC8909104Medicaid
NC013CTOtherBCBS
NC0186LOtherBCBS
NC790186LMedicaid