Provider Demographics
NPI:1003989187
Name:MARSHALL, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 RIDGE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4643
Mailing Address - Country:US
Mailing Address - Phone:712-325-0022
Mailing Address - Fax:712-325-8102
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-325-0022
Practice Address - Fax:712-325-8102
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA20313207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
20278OtherCOVENTRY
IA0166561Medicaid
0400056OtherUNITED HEALTH CARE
IA16656OtherWELLMARK
A01515Medicare UPIN
IA16656OtherWELLMARK
IA16656Medicare ID - Type Unspecified