Provider Demographics
NPI:1902887565
Name:MARVIN, MARK W (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:MARVIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12450 SUNDANCE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2241
Mailing Address - Country:US
Mailing Address - Phone:858-565-0066
Mailing Address - Fax:
Practice Address - Street 1:444 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3510
Practice Address - Country:US
Practice Address - Phone:858-565-0066
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11800103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY118000Medicaid