Provider Demographics
NPI:1467468413
Name:MARSHALL, JOHN BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRUCE
Last Name:MARSHALL
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 1:2322 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-3176
Mailing Address - Country:US
Mailing Address - Phone:216-363-2504
Mailing Address - Fax:216-241-5660
Practice Address - Street 1:2322 E 22ND ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3176
Practice Address - Country:US
Practice Address - Phone:216-363-2504
Practice Address - Fax:216-241-5660
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.036671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0284919Medicaid
OH0284919Medicaid
OHMA0403263Medicare ID - Type Unspecified