Provider Demographics
NPI:1477761765
Name:MARSHALL, GRANVILLE H JR (MD)
Entity Type:Individual
Prefix:
First Name:GRANVILLE
Middle Name:H
Last Name:MARSHALL
Suffix:JR
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 1:170 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-4282
Mailing Address - Country:US
Mailing Address - Phone:530-313-5529
Mailing Address - Fax:530-387-3581
Practice Address - Street 1:170 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4282
Practice Address - Country:US
Practice Address - Phone:530-313-5529
Practice Address - Fax:530-387-3581
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH12554Medicare UPIN
CAZZZ22136ZMedicare PIN