Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | K2068 | TX |
NPI | 1003878646 |
---|---|
Provider Name | Dr. Michael D. Marsh |
First Address | Weatherford, TX 76086-4703 |
Second Address | Weatherford, TX 76086-4703 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H77413 | (02) | TX |
K2068 | STATE LICENSE (01) | TX |