Provider Demographics
NPI:1174512032
Name:TAM, MARVIN K (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:K
Last Name:TAM
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 1:1201 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE 14000
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-2008
Mailing Address - Country:US
Mailing Address - Phone:480-545-8119
Mailing Address - Fax:480-892-6805
Practice Address - Street 1:6424 E BROADWAY RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1750
Practice Address - Country:US
Practice Address - Phone:480-456-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ283192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ513756Medicaid
G951113Medicare UPIN
AZZ165963Medicare PIN
62766Medicare ID - Type UnspecifiedARL
62767Medicare ID - Type UnspecifiedEVDI