Provider Demographics
NPI:1417038118
Name:LACUESTA, MARDEN B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARDEN
Middle Name:B
Last Name:LACUESTA
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 1:718 EAST WAYNE STREET
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822
Mailing Address - Country:US
Mailing Address - Phone:419-586-2523
Mailing Address - Fax:419-584-1617
Practice Address - Street 1:718 EAST WAYNE STREET
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822
Practice Address - Country:US
Practice Address - Phone:419-586-2523
Practice Address - Fax:419-584-1617
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043441207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0396905Medicaid
OH0396905Medicaid
OHLA0463582Medicare ID - Type Unspecified