Provider Demographics
NPI:1740385103
Name:MARSHALL, DEMETRI W (MD)
Entity Type:Individual
Prefix:
First Name:DEMETRI
Middle Name:W
Last Name:MARSHALL
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:P. O. BOX 741
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-4262
Mailing Address - Country:US
Mailing Address - Phone:601-437-3050
Mailing Address - Fax:601-437-3051
Practice Address - Street 1:2045 HIGHWAY 61 NORTH
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-4262
Practice Address - Country:US
Practice Address - Phone:601-437-3050
Practice Address - Fax:601-437-3051
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0017759Medicaid
C72547Medicare UPIN