Provider Demographics
NPI:1003399130
Name:MARC, CONSTANTIN RAUL
Entity Type:Individual
Prefix:
First Name:CONSTANTIN
Middle Name:RAUL
Last Name:MARC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 QUAIL RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-7153
Mailing Address - Country:US
Mailing Address - Phone:570-994-5105
Mailing Address - Fax:
Practice Address - Street 1:542 QUAIL RIDGE LN
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-7153
Practice Address - Country:US
Practice Address - Phone:570-994-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA5429372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology