Provider Demographics
NPI:1962056788
Name:MARMOR, ITAY (MD)
Entity type:Individual
Prefix:DR
First Name:ITAY
Middle Name:
Last Name:MARMOR
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 1:1 CHILDRENS PL CB 8116
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-454-6124
Mailing Address - Fax:314-454-4861
Practice Address - Street 1:1 CHILDRENS PL CB 8116
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-454-6124
Practice Address - Fax:314-454-4861
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019023813208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics