Provider Demographics
NPI:1811283005
Name:GRIFFIN FAGG, MARLEY A (DO)
Entity type:Individual
Prefix:DR
First Name:MARLEY
Middle Name:A
Last Name:GRIFFIN FAGG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MARLEY
Other - Middle Name:A
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:138 N DIXON RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-4154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 N DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901
Practice Address - Country:US
Practice Address - Phone:765-236-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-26
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019418207R00000X
IN02004405A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201232310Medicaid
IN558430169Medicare PIN