Provider Demographics
NPI:1932365533
Name:ALVISO, MARVIN CARSON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:CARSON
Last Name:ALVISO
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 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092447207Q00000X
IDM-11390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1932365533Medicaid
ID20003878Medicare PIN
ID20003881Medicare PIN
ID20003880Medicare PIN
ID20003879Medicare PIN
ID1932365533Medicaid