Provider Demographics
NPI:1992911929
Name:MARCO POLO OPTICA
Entity type:Organization
Organization Name:MARCO POLO OPTICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-649-4527
Mailing Address - Street 1:1701 W FLAGLER ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-2098
Mailing Address - Country:US
Mailing Address - Phone:305-649-4527
Mailing Address - Fax:
Practice Address - Street 1:1701 W FLAGLER ST STE 3
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2098
Practice Address - Country:US
Practice Address - Phone:305-649-4527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3569317156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086366100Medicaid