Provider Demographics
NPI:1417035221
Name:MARVIN, KENNETH S (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:MARVIN
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:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-535-3500
Mailing Address - Fax:
Practice Address - Street 1:101 HARRIS INDUSTRIAL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8852
Practice Address - Country:US
Practice Address - Phone:912-535-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075321207RC0000X
NY171074207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
E51986Medicare UPIN
00G658860Medicare ID - Type Unspecified
CA00G658860Medicaid