Provider Demographics
NPI:1497857817
Name:CORLETTE, MARVIN B (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:B
Last Name:CORLETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1413
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:MA
Mailing Address - Zip Code:02667-1413
Mailing Address - Country:US
Mailing Address - Phone:508-240-0208
Mailing Address - Fax:508-240-0499
Practice Address - Street 1:3130 STATE HWY RTE 6
Practice Address - Street 2:
Practice Address - City:WELLFLEET
Practice Address - State:MA
Practice Address - Zip Code:02667-7402
Practice Address - Country:US
Practice Address - Phone:508-349-3131
Practice Address - Fax:508-349-1311
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA30916208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAC46323Medicare UPIN
MAC1605901Medicare PIN