Provider Demographics
NPI:1235498254
Name:POOLE, MARVIN LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:LOUIS
Last Name:POOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARVIN
Other - Middle Name:LOUIS
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6 SOUTHRIDGE DR.
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-8802
Mailing Address - Country:US
Mailing Address - Phone:870-867-2932
Mailing Address - Fax:
Practice Address - Street 1:6 SOUTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-8802
Practice Address - Country:US
Practice Address - Phone:870-867-2932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-4964207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD04854Medicare UPIN