Provider Demographics
NPI:1780635292
Name:STATON, MARSHALL A III (MD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:A
Last Name:STATON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:ALEXANDER
Other - Last Name:STATON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1066
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-1066
Mailing Address - Country:US
Mailing Address - Phone:843-448-2824
Mailing Address - Fax:
Practice Address - Street 1:1601 N OAK ST
Practice Address - Street 2:SUITE 206 MYRTLE OFFICES
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3579
Practice Address - Country:US
Practice Address - Phone:843-448-2824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC73682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA315-7Medicaid
SCPA315-7Medicaid