Provider Demographics
NPI:1265740062
Name:TOLLEY, MARC D (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:D
Last Name:TOLLEY
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 1:31ST MEDICAL GROUP
Mailing Address - Street 2:UNIT 6180
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09604-6180
Mailing Address - Country:US
Mailing Address - Phone:314-632-5105
Mailing Address - Fax:
Practice Address - Street 1:31ST MEDICAL GROUP, UNIT 6180
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09604-6180
Practice Address - Country:US
Practice Address - Phone:314-632-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8874108-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology