Provider Demographics
NPI:1255317863
Name:MARVELLI, THOMAS L (M D)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:MARVELLI
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6273 GRANBURY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-3401
Mailing Address - Country:US
Mailing Address - Phone:817-346-7333
Mailing Address - Fax:817-346-7675
Practice Address - Street 1:6273 GRANBURY RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-3401
Practice Address - Country:US
Practice Address - Phone:817-346-7333
Practice Address - Fax:817-346-7675
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7848174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB24648Medicare UPIN
TX00GH24Medicare ID - Type Unspecified