Provider Demographics
NPI:1487745949
Name:MARCUM, CONLEY L JR (OD)
Entity type:Individual
Prefix:DR
First Name:CONLEY
Middle Name:L
Last Name:MARCUM
Suffix:JR
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 1:7463 WHITE HAWK DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-4808
Mailing Address - Country:US
Mailing Address - Phone:907-333-5305
Mailing Address - Fax:
Practice Address - Street 1:2011 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507
Practice Address - Country:US
Practice Address - Phone:907-336-4400
Practice Address - Fax:907-336-4414
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK204152W00000X
OH5327 T2236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
204206OtherCOLEVISION INSURANCE #
360756OtherNATIONAL VISION (NVA) #
AKOD0204Medicaid
U90794Medicare UPIN
AK152558Medicare ID - Type Unspecified