Healthcare Provider Details

I. General information

NPI: 1962056788
Provider Name (Legal Business Name): ITAY MARMOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL CB 8116
ST. LOUIS MO
63110
US

IV. Provider business mailing address

1 CHILDRENS PL CB 8116
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6124
  • Fax: 314-454-4861
Mailing address:
  • Phone: 314-454-6124
  • Fax: 314-454-4861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019023813
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: