Healthcare Provider Details

I. General information

NPI: 1285655282
Provider Name (Legal Business Name): MARINUS C NDIKUM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 STATE STREET HAMOT RADIOLOGY
ERIE PA
16550
US

IV. Provider business mailing address

717 STATE ST SUITE 16 LL
ERIE PA
16501
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-6000
  • Fax: 814-877-6149
Mailing address:
  • Phone: 814-480-7100
  • Fax: 814-480-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS012214
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: