Provider Demographics
NPI:1205868544
Name:MARIN, PHILIP CHARLES (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:CHARLES
Last Name:MARIN
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 1:1304 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2718
Mailing Address - Country:US
Mailing Address - Phone:719-669-8487
Mailing Address - Fax:719-669-8488
Practice Address - Street 1:1304 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2718
Practice Address - Country:US
Practice Address - Phone:719-669-8487
Practice Address - Fax:719-669-8488
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00405002086S0122X
CO40500208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
61101OtherHUMANA GOLD
00073OtherHMO CO
P00213540OtherMEDICARE RAILROAD
TDDIROtherTRICARE
00320OtherINSURANCE
COMA65799OtherBLUE CROSS BLUE SHIELD
71412OtherUNITED OF OMAHA