Provider Demographics
NPI:1982898771
Name:MARVIN, BENJAMIN D (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:D
Last Name:MARVIN
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 3202
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-3202
Mailing Address - Country:US
Mailing Address - Phone:907-707-1045
Mailing Address - Fax:
Practice Address - Street 1:2500 SOUTH WOODWARD LOOP
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-707-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7152207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN050002174Medicare PIN
MN050002310Medicare PIN