Provider Demographics
NPI:1457595001
Name:MARSHALL, MARK ABRAHAM
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ABRAHAM
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WILD RIVER LN
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-2023
Mailing Address - Country:US
Mailing Address - Phone:515-508-9223
Mailing Address - Fax:
Practice Address - Street 1:3300 DOUGLAS BLVD., SUITE 405
Practice Address - Street 2:EMP
Practice Address - City:ROSEVILL
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:330-493-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 12191207P00000X
OH34. 010307207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program