Provider Demographics
NPI:1093135154
Name:MARMALICH, DUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:MARMALICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4013 BEATLINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-4135
Mailing Address - Country:US
Mailing Address - Phone:228-200-0720
Mailing Address - Fax:228-200-0383
Practice Address - Street 1:4013 BEATLINE RD STE A
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560
Practice Address - Country:US
Practice Address - Phone:228-424-4425
Practice Address - Fax:228-200-0383
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS255432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04334707Medicaid