Provider Demographics
NPI:1740285063
Name:MARVEL, JEFFREY BLAINE (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAINE
Last Name:MARVEL
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2221
Mailing Address - Country:US
Mailing Address - Phone:931-455-2005
Mailing Address - Fax:931-455-4450
Practice Address - Street 1:1821 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2221
Practice Address - Country:US
Practice Address - Phone:931-455-2005
Practice Address - Fax:931-455-4450
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29420174400000X
MT87585207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3057919OtherBLUE CROSS BLUE SHIELD
TN3812095Medicaid
TNE36559Medicare UPIN
TN3057919OtherBLUE CROSS BLUE SHIELD