Provider Demographics
NPI:1164598819
Name:ALLEN, MARILYN J (DPM)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 BRUCE B DOWNS BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3906
Mailing Address - Country:US
Mailing Address - Phone:813-978-9008
Mailing Address - Fax:
Practice Address - Street 1:14201 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3906
Practice Address - Country:US
Practice Address - Phone:813-978-9008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 1355213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
59-2202191OtherFEDERAL TAX I.D.
FL87747Medicare ID - Type Unspecified
FLU21350Medicare UPIN