Provider Demographics
NPI:1386870673
Name:GENERILLO, MARLYN (MD)
Entity type:Individual
Prefix:
First Name:MARLYN
Middle Name:
Last Name:GENERILLO
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 1:909 FROSTWOOD DR
Mailing Address - Street 2:STE 1.100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2301
Mailing Address - Country:US
Mailing Address - Phone:713-338-4523
Mailing Address - Fax:
Practice Address - Street 1:4 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4127
Practice Address - Country:US
Practice Address - Phone:281-316-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093903207Q00000X
KY45673207Q00000X
TXQ1151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066982Medicaid
KY7100217820Medicaid
OH0066982Medicaid