Healthcare Provider Details

I. General information

NPI: 1023955259
Provider Name (Legal Business Name): MR. MARVIN VALENTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3817 JAMES STREET 124 BURMONT RD
DREXEL HILL PA
19026-2035
US

IV. Provider business mailing address

124 BURMONT RD
DREXEL HILL PA
19026-2035
US

V. Phone/Fax

Practice location:
  • Phone: 267-797-7789
  • Fax:
Mailing address:
  • Phone: 267-797-7789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number27508828
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: