Provider Demographics
NPI:1184671869
Name:MARQUEZ DE LEON, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:MARQUEZ DE LEON
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1640 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2684
Practice Address - Country:US
Practice Address - Phone:262-670-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI475552084N0400X
MN484872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1184671869Medicaid
WI462365002Medicare PIN
WI1184671869Medicaid
MN130001268Medicare ID - Type Unspecified
WI68086 1057Medicare PIN
MNI52491Medicare UPIN
WI019940765Medicare PIN