Healthcare Provider Details

I. General information

NPI: 1356322283
Provider Name (Legal Business Name): MARVIN R. BOREN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4642 HILLS DALES RD NW
CANTON OH
44708-1510
US

IV. Provider business mailing address

4642 HILLS DALES RD NW
CANTON OH
44708
US

V. Phone/Fax

Practice location:
  • Phone: 330-477-4400
  • Fax:
Mailing address:
  • Phone: 330-477-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36001949
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: