Healthcare Provider Details

I. General information

NPI: 1659549624
Provider Name (Legal Business Name): LARRY M MARCUS, MD, FACS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N MAIN ST
BRISTOL CT
06010-4972
US

IV. Provider business mailing address

255 N MAIN ST
BRISTOL CT
06010-4972
US

V. Phone/Fax

Practice location:
  • Phone: 860-585-5888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number029258
License Number StateCT

VIII. Authorized Official

Name: LARRY MARCUS
Title or Position: PHYSICIAN
Credential: MD
Phone: 860-585-5888