Provider Demographics
NPI:1194010322
Name:MARCUS, DEANNA MARIE
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MARIE
Last Name:MARCUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5828 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-3683
Mailing Address - Country:US
Mailing Address - Phone:317-918-4355
Mailing Address - Fax:
Practice Address - Street 1:5828 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-3683
Practice Address - Country:US
Practice Address - Phone:317-918-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10-012343-1171WH0202X
IN10-012345-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201011630AMedicaid