Provider Demographics
NPI:1356322283
Name:BOREN, MARVIN R (DPM)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:R
Last Name:BOREN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4642 HILLS DALES RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708
Mailing Address - Country:US
Mailing Address - Phone:330-477-4400
Mailing Address - Fax:
Practice Address - Street 1:4642 HILLS DALES RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1510
Practice Address - Country:US
Practice Address - Phone:330-477-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001949213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0433169Medicaid
OH0481916Medicare PIN
OHT80490Medicare UPIN