Provider Demographics
NPI:1255384053
Name:MARSHALL, IAN Y (M D)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:Y
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2687 LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9100
Mailing Address - Country:US
Mailing Address - Phone:843-572-0097
Mailing Address - Fax:843-725-3118
Practice Address - Street 1:641 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7165
Practice Address - Country:US
Practice Address - Phone:843-766-9747
Practice Address - Fax:843-766-3399
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14936208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4437Medicaid
SCE747328519Medicare UPIN
SC8519Medicare PIN