Healthcare Provider Details

I. General information

NPI: 1245157965
Provider Name (Legal Business Name): MARLON ARMANDO ARIAS INTRIAGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-9640
US

IV. Provider business mailing address

1120 15TH ST
AUGUSTA GA
30912-9640
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2771
  • Fax:
Mailing address:
  • Phone: 706-721-2771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number114064
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: