Provider Demographics
NPI:1669475737
Name:FOJTASEK, MARVIN F (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:F
Last Name:FOJTASEK
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 1:2790 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3884
Mailing Address - Country:US
Mailing Address - Phone:972-661-2273
Mailing Address - Fax:866-292-6489
Practice Address - Street 1:2790 LAKE VISTA DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3884
Practice Address - Country:US
Practice Address - Phone:972-661-2273
Practice Address - Fax:866-292-6489
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9429207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF9429OtherSTATE MEDICAL LICENSE NUMBER
TX120475212Medicaid
TX120475205Medicaid
TXF9429OtherSTATE MEDICAL LICENSE NUMBER
TX8J1885Medicare ID - Type Unspecified
TX120475205Medicaid
IN201510Medicare ID - Type Unspecified
TX8J1885Medicare ID - Type Unspecified
TX120475205Medicaid
TXF9429OtherMEDICAL LICENSE NUMBER
AF3088805OtherDEA NUMBER
IN1413687OtherFIRST HEALTH
IN201510Medicare ID - Type Unspecified
IL742664070TOtherBC/BS ILLINOIS
IN200366310BMedicaid
IN01036777AOtherMEDICAL LICENSE NUMBER