Provider Demographics
NPI: | 1245213891 |
---|---|
Name: | MARSHALL, EDWIN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | EDWIN |
Middle Name: | |
Last Name: | MARSHALL |
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: | PMB 202, PO BOX 70005 |
Mailing Address - Street 2: | |
Mailing Address - City: | FAJARDO |
Mailing Address - State: | PR |
Mailing Address - Zip Code: | 00738 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 787-860-0075 |
Mailing Address - Fax: | 787-863-6246 |
Practice Address - Street 1: | 375 AVE GEN VALERO |
Practice Address - Street 2: | SUITE 105 |
Practice Address - City: | FAJARDO |
Practice Address - State: | PR |
Practice Address - Zip Code: | 00738-4893 |
Practice Address - Country: | US |
Practice Address - Phone: | 787-860-0075 |
Practice Address - Fax: | 787-863-6246 |
Is Sole Proprietor?: | Not Answered |
Enumeration Date: | 2005-11-28 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PR | 8326 | 207R00000X, 207RC0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
Not Answered | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
E08572 | Medicare UPIN | ||
0029386 | Medicare ID - Type Unspecified |