Provider Demographics
NPI:1750379814
Name:MARINO, BRIAN JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:MARINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 N ACADIA RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4897
Mailing Address - Country:US
Mailing Address - Phone:985-446-1763
Mailing Address - Fax:985-446-9813
Practice Address - Street 1:604 N ACADIA RD
Practice Address - Street 2:SUITE 207
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4897
Practice Address - Country:US
Practice Address - Phone:985-446-1763
Practice Address - Fax:985-446-9813
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200188208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1647519Medicaid
LA1647519Medicaid
I34002Medicare UPIN