Provider Demographics
NPI:1174681092
Name:UPSHUR, MARSHALL LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:LEROY
Last Name:UPSHUR
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
Mailing Address - Street 2:2101 E JEFFERSON ST PPQA MEDICARE COMPLAINCE UNIT 6 W
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:14139 POTOMAC MILLS ROAD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4644
Practice Address - Country:US
Practice Address - Phone:703-490-8400
Practice Address - Fax:703-490-7635
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101037842152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
002120K32Medicare ID - Type Unspecified
F42337Medicare UPIN