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
StateLicense IDTaxonomies
IN01025402A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000000109463OtherANTHEM
IN100102470Medicaid
KY64871072OtherKY MEDICAID
IN080042780Medicare PIN
KY64871072OtherKY MEDICAID
IN849800NMedicare PIN
IN257900MMMedicare PIN