Provider Demographics
NPI:1528064656
Name:MARCIANO, MARK THOMAS (O D)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:MARCIANO
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1788 N. JOG RD.
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-0000
Mailing Address - Country:US
Mailing Address - Phone:561-242-1200
Mailing Address - Fax:561-242-1291
Practice Address - Street 1:1788 N. JOG RD.
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-0000
Practice Address - Country:US
Practice Address - Phone:561-242-1200
Practice Address - Fax:561-242-1291
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP3248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620930100Medicaid
FL20844XMedicare PIN
FL620930100Medicaid