Provider Demographics
NPI:1386692382
Name:GEORGE, MARILYN L (OD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:L
Last Name:GEORGE
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 1:100 PARKER CT
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024
Mailing Address - Country:US
Mailing Address - Phone:440-286-9555
Mailing Address - Fax:440-286-6005
Practice Address - Street 1:100 PARKER CT
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024
Practice Address - Country:US
Practice Address - Phone:440-286-9555
Practice Address - Fax:440-286-6135
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3076152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000132357OtherANTHEM
OH0257190Medicaid
0426980001Medicare NSC
000000132357OtherANTHEM