Basic Information
| Provider Information | |||||||||
| NPI: | 1205863644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARRUFO | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARRUFO | ||||||||
| OtherFirstName: | MANUEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 126 | ||||||||
| Address2: | |||||||||
| City: | CHRISTIANSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240682147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409515090 | ||||||||
| FaxNumber: | 5409515094 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 DAVIS ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | BLACKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240607013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409515090 | ||||||||
| FaxNumber: | 5409515094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 12/10/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 0101238524 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 053995 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P00319701 | 01 | VA | RAILROAD MEDICARE | OTHER | 5905670 | 05 | NC | MEDICAID | 010275091 | 05 | VA | MEDICAID | 1205863644 | 01 | VA | NPI | OTHER |