Basic Information
| Provider Information | |||||||||
| NPI: | 1629304191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALDRICH | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207261 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 W PETERSON AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606593307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 8539T | TX | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 091381 | IA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 3447ATI | OR | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OD60293969 | WA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 046011389 | IL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2687 | NC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.