Provider Demographics
NPI:1740226265
Name:MARLETT, MYRON M (MD)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:M
Last Name:MARLETT
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 1:2845 GREENBRIER RD STE 240
Mailing Address - Street 2:PO BOX 890
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8280
Mailing Address - Fax:920-288-8285
Practice Address - Street 1:2845 GREENBRIER RD STE 240
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8280
Practice Address - Fax:920-288-8385
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21501208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI340015993OtherRAILROAD
WI30180200Medicaid
MI104384598Medicaid
MI3402100582OtherBCBS
WI003771460Medicare PIN
MIM82740004Medicare PIN
WIB54831Medicare UPIN
MI104384598Medicaid