Provider Demographics
NPI:1962862508
Name:KERWIN, MARLA BLAIR (DO)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:BLAIR
Last Name:KERWIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 WATKINS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1435
Mailing Address - Country:US
Mailing Address - Phone:248-763-7830
Mailing Address - Fax:
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:BOX 162
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025706207LP3000X, 207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program