Provider Demographics
NPI:1063801686
Name:AUSTIN, MARCELLUS SR
Entity type:Individual
Prefix:
First Name:MARCELLUS
Middle Name:
Last Name:AUSTIN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3342 BROADWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1688
Mailing Address - Country:US
Mailing Address - Phone:214-469-8628
Mailing Address - Fax:
Practice Address - Street 1:3342 BROADWAY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-1688
Practice Address - Country:US
Practice Address - Phone:214-469-8628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator