Provider Demographics
NPI:1609857424
Name:SPULLER, MARC EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:EDWARD
Last Name:SPULLER
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:CMR 431
Mailing Address - Street 2:BOX 919
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09175
Mailing Address - Country:DE
Mailing Address - Phone:4906155-600-9216
Mailing Address - Fax:
Practice Address - Street 1:CMR 431
Practice Address - Street 2:DARMSTADT HEALTH CLINIC
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09175
Practice Address - Country:DE
Practice Address - Phone:490615-169-6474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047490208000000X
MN28303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0164370Medicaid
D82185Medicare UPIN
OH0164370Medicaid