Provider Demographics
NPI:1447209887
Name:YAGUDAEV, MARINA (O D)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:YAGUDAEV
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100 COLLINS AVE #112
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3675
Mailing Address - Country:US
Mailing Address - Phone:305-917-1037
Mailing Address - Fax:305-917-1337
Practice Address - Street 1:17100 COLLINS AVE #112
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES
Practice Address - State:FL
Practice Address - Zip Code:33160-3675
Practice Address - Country:US
Practice Address - Phone:305-917-1037
Practice Address - Fax:305-917-1337
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC3753OtherOPTOMETRIST LICENSE