Provider Demographics
NPI:1164402103
Name:RAY, MARVIN LEE (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:LEE
Last Name:RAY
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 1:200 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3808
Mailing Address - Country:US
Mailing Address - Phone:513-424-2535
Mailing Address - Fax:513-424-0363
Practice Address - Street 1:200 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3808
Practice Address - Country:US
Practice Address - Phone:513-424-2535
Practice Address - Fax:513-424-0363
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH074010207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2093050Medicaid
OH663787Medicaid
OH2093050Medicaid
OHH374520Medicare PIN
OHRA0881271Medicare ID - Type Unspecified