Provider Demographics
NPI:1346977410
Name:HENRY, MARINA (OD)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:HENRY
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 AVENUE OF THE ARTS APT F224
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-7629
Mailing Address - Country:US
Mailing Address - Phone:713-517-4481
Mailing Address - Fax:
Practice Address - Street 1:1130 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3538
Practice Address - Country:US
Practice Address - Phone:310-323-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10653TG152W00000X
CA35893TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist