Provider Demographics
NPI:1063442606
Name:MARMOL, LUIS GERARDO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GERARDO
Last Name:MARMOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 HARBOR BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5344
Mailing Address - Country:US
Mailing Address - Phone:941-235-1901
Mailing Address - Fax:941-235-1905
Practice Address - Street 1:2525 HARBOR BLVD
Practice Address - Street 2:SUITE # 303
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5317
Practice Address - Country:US
Practice Address - Phone:941-235-1901
Practice Address - Fax:941-235-1905
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68622207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040010592OtherRAILROAD MEDICARE
FLP00609303OtherRAILROAD MEDICARE
P00913646OtherRAILROAD MEDICARE
FL27258ZMedicare PIN
G07471Medicare UPIN