Provider Demographics
NPI:1164751319
Name:MARSHALL, COLIN THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:THOMAS
Last Name:MARSHALL
Suffix:
Gender:M
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-5300
Mailing Address - Fax:
Practice Address - Street 1:200 N 400 E
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759-7803
Practice Address - Country:US
Practice Address - Phone:435-676-2252
Practice Address - Fax:435-676-1544
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT361780-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1164751319Medicaid
UTU000072187Medicare PIN