Healthcare Provider Details

I. General information

NPI: 1205768983
Provider Name (Legal Business Name): KEVYN MARSHALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10220 W SAMPLE RD
CORAL SPRINGS FL
33065-3940
US

IV. Provider business mailing address

5613 NW 117TH AVE
CORAL SPRINGS FL
33076-3617
US

V. Phone/Fax

Practice location:
  • Phone: 954-340-1123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11047882
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: