Provider Demographics
NPI:1366519837
Name:HERTZEL, MARVIN (OD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:HERTZEL
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 1:23 ARBORO DR
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1157 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2135
Practice Address - Country:US
Practice Address - Phone:781-963-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0018029OtherNHP
MA0307408Medicaid
150494OtherHPHC
22-00404OtherUNITED
7497849003OtherCIGNA
000000022736OtherBMC
725512OtherTUFTS
84787OtherAETNA
W15493OtherBCBS
725512OtherTUFTS
MA0307408Medicaid