Provider Demographics
NPI:1740455864
Name:MARIN, ETHAN (MD PHD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:MARIN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 CEDAR ST
Mailing Address - Street 2:BB114
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3218
Mailing Address - Country:US
Mailing Address - Phone:203-785-4185
Mailing Address - Fax:
Practice Address - Street 1:330 CEDAR ST
Practice Address - Street 2:BB114
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-785-4185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT047176207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program