Provider Demographics
NPI:1992786420
Name:VESTAL, MARIETTA T (OD)
Entity type:Individual
Prefix:
First Name:MARIETTA
Middle Name:T
Last Name:VESTAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARIETTA
Other - Middle Name:TEMPLIN
Other - Last Name:VESTAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:910 TUSCULUM BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4004
Mailing Address - Country:US
Mailing Address - Phone:423-639-2002
Mailing Address - Fax:423-638-4522
Practice Address - Street 1:910 TUSCULUM BLVD
Practice Address - Street 2:STE 2
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4004
Practice Address - Country:US
Practice Address - Phone:423-639-2002
Practice Address - Fax:423-638-4522
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000000490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3593480Medicaid
TN3593480Medicaid
TN3593480Medicare ID - Type Unspecified