Provider Demographics
NPI:1336146059
Name:COLVIN, MARVIN L (DO)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:L
Last Name:COLVIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 N MAIN ST
Mailing Address - Street 2:STE. A
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3649
Mailing Address - Country:US
Mailing Address - Phone:928-634-7470
Mailing Address - Fax:928-639-3280
Practice Address - Street 1:753 N MAIN ST
Practice Address - Street 2:STE. A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3649
Practice Address - Country:US
Practice Address - Phone:928-634-7470
Practice Address - Fax:928-639-3280
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDO2771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ111112Medicaid
AZE97686Medicare UPIN
AZZDO2771Medicare PIN