Provider Demographics
NPI:1467550079
Name:ASTLE, MARVIN JEREMY (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:JEREMY
Last Name:ASTLE
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 1:1954 FORT UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6800
Mailing Address - Country:US
Mailing Address - Phone:801-993-9530
Mailing Address - Fax:
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:801-993-9530
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5898976-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT243341OtherALTIUS
UTQMP000002261759OtherMOLINA
UT82347OtherPEHP
UT88999OtherHEALTHY U
UT107389211101OtherIHC
UT902487OtherDESERET MUTUAL
UT82347OtherPEHP