Provider Demographics
NPI:1386038750
Name:ESCOBEDO, MARCO ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:ANTONIO
Last Name:ESCOBEDO
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:PO BOX 336810
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-6810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 AVE TITO CASTRO
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-843-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10052386207Q00000X
PR34027207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR34027Medicaid