Basic Information
| Provider Information | |||||||||
| NPI: | 1306827365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DZIABIS | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 275 W 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PERU | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469701638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654728000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 01019407A | IN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207U00000X | 01019407A | IN | N | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 220008472 | 01 | RAILROAD | OTHER |