Provider Demographics
NPI:1992911150
Name:MARROTTE, JILL M (OD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:MARROTTE
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 1:430 3RD AVE S APT 332
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4189
Mailing Address - Country:US
Mailing Address - Phone:561-212-8585
Mailing Address - Fax:
Practice Address - Street 1:148 13TH ST SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3127
Practice Address - Country:US
Practice Address - Phone:727-450-3032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2075152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100787800Medicaid