Provider Demographics
NPI:1306825872
Name:PEREZ-MARQUARDT, IRIS THEODORA CINCO (MD)
Entity Type:Individual
Prefix:
First Name:IRIS THEODORA
Middle Name:CINCO
Last Name:PEREZ-MARQUARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRIS THEODORA
Other - Middle Name:CINCO
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:107 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1002
Practice Address - Country:US
Practice Address - Phone:920-846-3092
Practice Address - Fax:920-846-8313
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38426-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32348900Medicaid
WI11014110Medicaid
WI1851477913OtherCMH NPI
WI1467583096OtherCMH PCC OF NPI
WI1326349135OtherCMH SB NPI
WIG58034Medicare UPIN
WI11014110Medicaid