Provider Demographics
NPI:1366401853
Name:BASE, MARVIN J (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:J
Last Name:BASE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9308 QUEENS BLVD # 1B1C
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1135
Mailing Address - Country:US
Mailing Address - Phone:718-806-1434
Mailing Address - Fax:718-806-1435
Practice Address - Street 1:9308 QUEENS BLVD # 1B1C
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1135
Practice Address - Country:US
Practice Address - Phone:718-806-1434
Practice Address - Fax:718-806-1435
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2024-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY187770207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01888251Medicaid