Provider Demographics
NPI:1235109455
Name:BURENKO, MARCO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:
Last Name:BURENKO
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 1:657 BREVARD AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922
Mailing Address - Country:US
Mailing Address - Phone:321-632-6880
Mailing Address - Fax:
Practice Address - Street 1:699 W COCOA BCH CSWY
Practice Address - Street 2:STE 203
Practice Address - City:COCA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931
Practice Address - Country:US
Practice Address - Phone:321-799-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL51687207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049442900Medicaid
E21386Medicare UPIN
FL049442900Medicaid