Provider Demographics
NPI:1104156819
Name:BAULA, MARVIN (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:
Last Name:BAULA
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 1:1101 SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45237-2621
Mailing Address - Country:US
Mailing Address - Phone:513-948-3721
Mailing Address - Fax:513-948-8631
Practice Address - Street 1:4464 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45005-5464
Practice Address - Country:US
Practice Address - Phone:513-649-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0999252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074946OtherMEDICAID-ODMH
OH01-0693OtherCARF CERTIFICATION
OH0074861OtherMEDICAID-ODADAS
OHH130910OtherMEDICARE GROUP PTAN