Provider Demographics
NPI:1568660652
Name:COMMODORE, MARIUS MARCEL (MD)
Entity type:Individual
Prefix:
First Name:MARIUS
Middle Name:MARCEL
Last Name:COMMODORE
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-1800
Mailing Address - Fax:215-707-3644
Practice Address - Street 1:1523 SAINT CHARLES AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130-4445
Practice Address - Country:US
Practice Address - Phone:215-707-1800
Practice Address - Fax:215-707-3644
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD446997207R00000X
TXM65742084P0800X, 207R00000X
LA323144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188964402Medicaid
TX188964401Medicaid
TX8J7725Medicare PIN
TX8K3266Medicare PIN