Provider Demographics
NPI:1861583486
Name:MARSHALL, DANIEL R (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1605
Mailing Address - Country:US
Mailing Address - Phone:208-359-4841
Mailing Address - Fax:208-359-4842
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-359-4841
Practice Address - Fax:208-359-4842
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018423207P00000X
IDO-0508207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808295400Medicaid