Provider Demographics
NPI:1164790713
Name:MARSHALL, DEREK
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:MARSHALL
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 1:1316 VIRGINIA ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3054
Mailing Address - Country:US
Mailing Address - Phone:800-225-5288
Mailing Address - Fax:
Practice Address - Street 1:1316 VIRGINIA ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3054
Practice Address - Country:US
Practice Address - Phone:800-225-5288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-11
Last Update Date:2017-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program