Provider Demographics
NPI:1992894232
Name:MERRELL, MARSHALL H (OD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:H
Last Name:MERRELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N 2ND E
Mailing Address - Street 2:STE 1
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1603
Mailing Address - Country:US
Mailing Address - Phone:208-359-2020
Mailing Address - Fax:208-359-2021
Practice Address - Street 1:46 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2047
Practice Address - Country:US
Practice Address - Phone:208-359-2020
Practice Address - Fax:208-359-2021
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP813152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015276OtherREGENCE BLUE SHIELD
IDV7261OtherBLUE CROSS OF IDAHO
ID002652200Medicaid
ID000010015275OtherREGENCE BLUE SHIELD
IDV3058OtherBLUE CROSS OF IDAHO
IDV7261OtherBLUE CROSS OF IDAHO
ID000010015275OtherREGENCE BLUE SHIELD
ID000010015276OtherREGENCE BLUE SHIELD
IDV3058OtherBLUE CROSS OF IDAHO