Provider Demographics
NPI:1114412137
Name:MARQUEZ, ILEANA (MD)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 HOMESTEAD RD N STE 102
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6049
Mailing Address - Country:US
Mailing Address - Phone:239-303-2700
Mailing Address - Fax:239-303-2756
Practice Address - Street 1:1303 HOMESTEAD RD N STE 102
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6049
Practice Address - Country:US
Practice Address - Phone:239-303-2700
Practice Address - Fax:239-303-2756
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14575I390200000X
FLACN1263208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN1263OtherFLORIDA ACN MEDICAL LICENSE
FLFM8379542OtherDEA