Healthcare Provider Details

I. General information

NPI: 1518660570
Provider Name (Legal Business Name): JEFFREY WINTON MARSAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 LANEY WALKER BLVD
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

4682 CUTTER MILL RD
MARTINEZ GA
30907-9365
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-7005
  • Fax:
Mailing address:
  • Phone: 650-862-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15303
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: