Basic Information
Provider Information | |||||||||
NPI: | 1720087059 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARSHALL | ||||||||
FirstName: | MYLON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10470 OLD PLACERVILLE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958272539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004700071 | ||||||||
FaxNumber: | 9167317877 | ||||||||
Practice Location | |||||||||
Address1: | 2801 K ST | ||||||||
Address2: | SUITE 502 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958165120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8775150053 | ||||||||
FaxNumber: | 9164546926 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2005 | ||||||||
LastUpdateDate: | 02/04/2014 | ||||||||
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 | 2085B0100X | G67047 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | G67047 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | G67047 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | G67047 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0203X | G67047 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | G67047 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0205X | G67047 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiological Physics | 2085U0001X | G67047 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
No ID Information.