Provider Demographics
NPI:1154581205
Name:MENJIVAR, ANNE MARIE (OD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:MENJIVAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 SW 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-4445
Mailing Address - Country:US
Mailing Address - Phone:352-622-5183
Mailing Address - Fax:352-622-2720
Practice Address - Street 1:1500 SE MAGNOLIA EXT
Practice Address - Street 2:SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4463
Practice Address - Country:US
Practice Address - Phone:352-622-5183
Practice Address - Fax:352-622-2720
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4393152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001244700Medicaid
FLCG733ZMedicare PIN