Provider Demographics
NPI:1154436665
Name:IM, MARVIN (DO)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 POST RD STE 102
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-1347
Mailing Address - Country:US
Mailing Address - Phone:614-813-0883
Mailing Address - Fax:614-813-7173
Practice Address - Street 1:6425 POST RD STE 102
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-1347
Practice Address - Country:US
Practice Address - Phone:614-813-0883
Practice Address - Fax:614-813-7173
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2285781Medicaid
OHIM4198902Medicare PIN
OHH46835Medicare UPIN