Healthcare Provider Details

I. General information

NPI: 1831522366
Provider Name (Legal Business Name): MARVIN LOUIS ROY YAP LU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY STE 301
DAYTONA BEACH FL
32117-5157
US

IV. Provider business mailing address

305 MEMORIAL MEDICAL PKWY STE 301
DAYTONA BEACH FL
32117-5157
US

V. Phone/Fax

Practice location:
  • Phone: 386-615-1521
  • Fax: 386-673-2787
Mailing address:
  • Phone: 386-615-1521
  • Fax: 386-673-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD458548
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT203514
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME161538
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: