Provider Demographics
NPI:1093020133
Name:BIRD, MARIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIEL
Middle Name:
Last Name:BIRD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4222
Mailing Address - Country:US
Mailing Address - Phone:330-965-8760
Mailing Address - Fax:602-938-9325
Practice Address - Street 1:987 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4222
Practice Address - Country:US
Practice Address - Phone:330-965-8760
Practice Address - Fax:330-965-9325
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006424207N00000X
FLUO2494208D00000X
OH34.012984207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ166728OtherMEDICARE PTAN