Healthcare Provider Details

I. General information

NPI: 1205868544
Provider Name (Legal Business Name): PHILIP CHARLES MARIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/05/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 N GRAND AVE
PUEBLO CO
81003-2718
US

IV. Provider business mailing address

1304 N GRAND AVE
PUEBLO CO
81003-2718
US

V. Phone/Fax

Practice location:
  • Phone: 719-669-8487
  • Fax: 719-669-8488
Mailing address:
  • Phone: 719-669-8487
  • Fax: 719-669-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number40500
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number40500
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number0040500
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: