Provider Demographics
NPI:1336115518
Name:JENNINGS, MARVIN EEVAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:EEVAN
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 HUNTER AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1543
Mailing Address - Country:US
Mailing Address - Phone:718-676-5262
Mailing Address - Fax:
Practice Address - Street 1:3307 HUNTER AVE
Practice Address - Street 2:APT 1
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1543
Practice Address - Country:US
Practice Address - Phone:718-676-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004966-1213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281429Medicaid
NYP54471Medicare ID - Type UnspecifiedMEDICARE #
NYU29320Medicare UPIN