Provider Demographics
NPI:1700817194
Name:STALTER, MARVIN D (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:D
Last Name:STALTER
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 1:12306 COUNTY ROAD E35
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-8309
Mailing Address - Country:US
Mailing Address - Phone:419-630-0491
Mailing Address - Fax:419-630-0491
Practice Address - Street 1:12306 COUNTY ROAD E 35
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-2409
Practice Address - Country:US
Practice Address - Phone:419-630-0491
Practice Address - Fax:419-630-0491
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-076325207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080161175OtherRAILROAD
OH2117524Medicaid
OH0879754Medicare PIN
OH2117524Medicaid