Healthcare Provider Details

I. General information

NPI: 1821452947
Provider Name (Legal Business Name): MARVELL SAINT-VICTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2321
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE-14301
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2022040061
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2022-0899
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: