Provider Demographics
NPI:1407044399
Name:SPANN, MARVIN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:DOUGLAS
Last Name:SPANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35914
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5914
Mailing Address - Country:US
Mailing Address - Phone:702-998-8486
Mailing Address - Fax:702-998-8282
Practice Address - Street 1:2615 BOX CANYON DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0450
Practice Address - Country:US
Practice Address - Phone:702-998-8486
Practice Address - Fax:702-998-8282
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6664375-1205208200000X
NV13247208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCK148ZMedicare PIN