Provider Demographics
NPI:1407811870
Name:CHAGUA, MARLON R (MD)
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:R
Last Name:CHAGUA
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 1:4001 KRESGE WAY STE 236
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4640
Mailing Address - Country:US
Mailing Address - Phone:502-893-7372
Mailing Address - Fax:502-409-4715
Practice Address - Street 1:4001 KRESGE WAY STE 236
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4640
Practice Address - Country:US
Practice Address - Phone:502-893-7372
Practice Address - Fax:502-409-4715
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH72747Medicare UPIN