Healthcare Provider Details

I. General information

NPI: 1417035221
Provider Name (Legal Business Name): KENNETH S MARVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 GLASSON WAY
GRASS VALLEY CA
95945-5723
US

IV. Provider business mailing address

155 GLASSON WAY
GRASS VALLEY CA
95945-5723
US

V. Phone/Fax

Practice location:
  • Phone: 530-274-6000
  • Fax:
Mailing address:
  • Phone: 530-274-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG65886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: