Provider Demographics
NPI:1386617868
Name:DATZMAN, MARILYN A (MD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:A
Last Name:DATZMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-7398
Mailing Address - Country:US
Mailing Address - Phone:541-997-8412
Mailing Address - Fax:541-997-9650
Practice Address - Street 1:400 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-7398
Practice Address - Country:US
Practice Address - Phone:541-997-8412
Practice Address - Fax:541-997-9650
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21534207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130139Medicaid
B29091Medicare UPIN
ORR103010Medicare PIN
ORR141861Medicare PIN
OR130139Medicaid