Healthcare Provider Details

I. General information

NPI: 1033223276
Provider Name (Legal Business Name): JONAH MARSHALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S MANNING BLVD STE 106
ALBANY NY
12208-1743
US

IV. Provider business mailing address

PO BOX 14890
ALBANY NY
12212-4890
US

V. Phone/Fax

Practice location:
  • Phone: 518-438-1019
  • Fax: 518-489-7642
Mailing address:
  • Phone: 518-525-5634
  • Fax: 518-649-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number238757
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: