Provider Demographics
NPI:1548250277
Name:MARDEN, JAC DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:JAC
Middle Name:DANIEL
Last Name:MARDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 S MARKET ST STE 206
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2259
Mailing Address - Country:US
Mailing Address - Phone:808-249-8600
Mailing Address - Fax:561-659-0495
Practice Address - Street 1:99 S MARKET ST STE 206
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2259
Practice Address - Country:US
Practice Address - Phone:808-249-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071733207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
322862Medicare ID - Type Unspecified
F86325Medicare UPIN