Healthcare Provider Details

I. General information

NPI: 1144274275
Provider Name (Legal Business Name): DON A MARSHALL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 E STATE BLVD SUTIE 100
FORT WAYNE IN
46805-4700
US

IV. Provider business mailing address

3010 E STATE BLVD SUTIE 100
FORT WAYNE IN
46805-4700
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-0632
  • Fax: 260-471-3451
Mailing address:
  • Phone: 260-471-0632
  • Fax: 260-471-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01038606A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number01038606A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number01038606A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: