Provider Demographics
NPI:1932190055
Name:LINNELL, MARY ELIZABETH (OD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:LINNELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:619-532-5840
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-5840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002666152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN