Provider Demographics
NPI:1417950635
Name:MARINO, CHRIS J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:J
Last Name:MARINO
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 1:12670 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3619
Mailing Address - Country:US
Mailing Address - Phone:239-936-3554
Mailing Address - Fax:239-936-8993
Practice Address - Street 1:12670 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3619
Practice Address - Country:US
Practice Address - Phone:239-936-3554
Practice Address - Fax:239-936-8993
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00692582084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254385100Medicaid
FLG66234Medicare UPIN
FL254385100Medicaid
FL42548XMedicare PIN
FL42548YMedicare PIN