Healthcare Provider Details

I. General information

NPI: 1205570850
Provider Name (Legal Business Name): MARSHALL BALDERSTON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 W OUTER DR
DETROIT MI
48235-2624
US

IV. Provider business mailing address

33437 HAMPTON RD
EUGENE OR
97405-9539
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-3250
  • Fax:
Mailing address:
  • Phone: 541-556-5129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101029284
License Number StateMI
# 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: