Provider Demographics
NPI:1952341992
Name:MARSHALL, V BLAKE JR (DO)
Entity Type:Individual
Prefix:DR
First Name:V
Middle Name:BLAKE
Last Name:MARSHALL
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:VIRGIL
Other - Middle Name:BLAKE
Other - Last Name:MARSHALL
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2410 DELANCEY ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6409
Mailing Address - Country:US
Mailing Address - Phone:215-732-7178
Mailing Address - Fax:215-725-4877
Practice Address - Street 1:2230 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19149-1230
Practice Address - Country:US
Practice Address - Phone:215-685-0603
Practice Address - Fax:215-725-4877
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005994207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001133997Medicaid
PA066692Medicare ID - Type Unspecified
PA001133997Medicaid