Healthcare Provider Details

I. General information

NPI: 1497857817
Provider Name (Legal Business Name): MARVIN B CORLETTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 STATE HWY RTE 6
WELLFLEET MA
02667-7402
US

IV. Provider business mailing address

PO BOX 1413
WELLFLEET MA
02667-1413
US

V. Phone/Fax

Practice location:
  • Phone: 508-349-3131
  • Fax: 508-349-1311
Mailing address:
  • Phone: 508-240-0208
  • Fax: 508-240-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number30916
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: