Provider Demographics
NPI:1770566861
Name:CUNNINGHAM, MARSHALL WADE (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:WADE
Last Name:CUNNINGHAM
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:PO BOX 294145
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78029-4145
Mailing Address - Country:US
Mailing Address - Phone:888-779-3675
Mailing Address - Fax:803-896-5211
Practice Address - Street 1:1020 S STATE HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4471
Practice Address - Country:US
Practice Address - Phone:830-997-4353
Practice Address - Fax:830-990-1599
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9037208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX611957Medicare ID - Type Unspecified
TXB61468Medicare UPIN