Provider Demographics
NPI:1063832210
Name:MARVIN, KASTLEY
Entity Type:Individual
Prefix:
First Name:KASTLEY
Middle Name:
Last Name:MARVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL MEDICAL CENTER CAMP LEJEUNE
Mailing Address - Street 2:100 BREWSTER BLVD
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER CAMP LEJEUNE
Practice Address - Street 2:100 BREWSTER BLVD
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547
Practice Address - Country:US
Practice Address - Phone:910-450-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101258930207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN