Provider Demographics
NPI:1205820958
Name:MIRVISS, MARSHAL J (MD)
Entity Type:Individual
Prefix:
First Name:MARSHAL
Middle Name:J
Last Name:MIRVISS
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:PO BOX 689711
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53268-9711
Mailing Address - Country:US
Mailing Address - Phone:414-456-3100
Mailing Address - Fax:414-456-3113
Practice Address - Street 1:2025 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4455
Practice Address - Country:US
Practice Address - Phone:414-389-2790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20062207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30178100Medicaid
WI046873840Medicare Oscar/Certification
WI30178100Medicaid
WI042768480Medicare Oscar/Certification
WIB55153Medicare UPIN