Healthcare Provider Details

I. General information

NPI: 1336115518
Provider Name (Legal Business Name): MARVIN EEVAN JENNINGS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 HUNTER AVE APT 1
BRONX NY
10475-1543
US

IV. Provider business mailing address

3307 HUNTER AVE APT 1
BRONX NY
10475-1543
US

V. Phone/Fax

Practice location:
  • Phone: 718-676-5262
  • Fax:
Mailing address:
  • Phone: 718-676-5262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN004966-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: