Provider Demographics
NPI:1699798603
Name:MARBLE, MICHAEL RAY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:MARBLE
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 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:CHILDREN'S HOSPITAL - GENETICS
Practice Address - Street 2:200 HENRY CLAY AVE
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118
Practice Address - Country:US
Practice Address - Phone:504-896-9254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10120R207SG0201X, 207SG0202X, 208000000X
NM89-257207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112369Medicaid
LA1974358Medicaid
LA5R985F669Medicare PIN
LA5R985Medicare PIN
E22704Medicare UPIN
LAP00318333Medicare PIN