Provider Demographics
NPI:1871584144
Name:BURT, MARLON G (OD)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:G
Last Name:BURT
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 1:90 CEDAR LIGHT LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-6978
Mailing Address - Country:US
Mailing Address - Phone:843-280-8779
Mailing Address - Fax:843-280-8779
Practice Address - Street 1:90 CEDAR LIGHT LN
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-6978
Practice Address - Country:US
Practice Address - Phone:843-280-8779
Practice Address - Fax:843-280-6669
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001552152W00000X
SC2374152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2374OtherSTATE LICENSE
250197OtherHEALTH ASSURANCE
1232505OtherCIGNA
50041186OtherCAPITOL BLUE
BU904393OtherBLUE S
SCD23749Medicaid
PA084965TDDMedicare PIN