Provider Demographics
NPI:1225095284
Name:MANDUCA-MARQUEZ, VIVIAN (AP, DOM)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:MANDUCA-MARQUEZ
Suffix:
Gender:F
Credentials:AP, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 VILLAGE DR
Mailing Address - Street 2:SUITE 16
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7067
Mailing Address - Country:US
Mailing Address - Phone:910-989-0002
Mailing Address - Fax:910-353-9753
Practice Address - Street 1:215 WESTERN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5732
Practice Address - Country:US
Practice Address - Phone:910-989-0002
Practice Address - Fax:910-353-9753
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC379171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC-0585OtherBLUE CROSS BLUE SHIELD FL