Healthcare Provider Details

I. General information

NPI: 1740226265
Provider Name (Legal Business Name): MYRON M MARLETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD STE 240
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

2845 GREENBRIER RD STE 240 PO BOX 890
GREEN BAY WI
54308-8900
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8280
  • Fax: 920-288-8385
Mailing address:
  • Phone: 920-288-8280
  • Fax: 920-288-8285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number21501
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: