Provider Demographics
NPI: | 1629145289 |
---|---|
Name: | MARIENAU, DAVID JOEL (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | DAVID |
Middle Name: | JOEL |
Last Name: | MARIENAU |
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: | PO BOX 3868 |
Mailing Address - Street 2: | |
Mailing Address - City: | EVANSVILLE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47737-3868 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 812-429-1818 |
Mailing Address - Fax: | 812-426-9564 |
Practice Address - Street 1: | 545 S BOEHNE CAMP RD |
Practice Address - Street 2: | |
Practice Address - City: | EVANSVILLE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47712-3703 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-429-1818 |
Practice Address - Fax: | 812-426-9564 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-11-29 |
Last Update Date: | 2013-01-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 01025402A | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 000000109463 | Other | ANTHEM |
IN | 100102470 | Medicaid | |
KY | 64871072 | Other | KY MEDICAID |
IN | 080042780 | Medicare PIN | |
KY | 64871072 | Other | KY MEDICAID |
IN | 849800N | Medicare PIN | |
IN | 257900MM | Medicare PIN |