Basic Information
| Provider Information | |||||||||
| NPI: | 1881001626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLDERBY | ||||||||
| FirstName: | MARI | ||||||||
| MiddleName: | SHELLY | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 3212212047 | ||||||||
| Practice Location | |||||||||
| Address1: | 7912 FOREST CITY RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328102907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 3212212047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC4915 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 012769900 | 05 | FL | MEDICAID |