Provider Demographics
NPI:1104374701
Name:MARINAS, ALLAN
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:
Last Name:MARINAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 EAGLE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-6902
Mailing Address - Country:US
Mailing Address - Phone:224-650-9286
Mailing Address - Fax:
Practice Address - Street 1:1603 EAGLE GROVE CT
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-6902
Practice Address - Country:US
Practice Address - Phone:224-650-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.010238171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor