Provider Demographics
NPI:1336241207
Name:TEITELBAUM, MARSHALL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:L
Last Name:TEITELBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARSHALL
Other - Middle Name:L
Other - Last Name:TEITELBAUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:641 UNIVERSITY BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2794
Mailing Address - Country:US
Mailing Address - Phone:561-630-8530
Mailing Address - Fax:561-630-8531
Practice Address - Street 1:641 UNIVERSITY BLVD
Practice Address - Street 2:SU. 206
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2791
Practice Address - Country:US
Practice Address - Phone:561-630-8530
Practice Address - Fax:561-630-8531
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00645202084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0064520OtherMEDICAL LICENSE
FL377387600Medicaid