Provider Demographics
NPI:1477963072
Name:C. D. DEMARQUE, MD, PA
Entity Type:Organization
Organization Name:C. D. DEMARQUE, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMARQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-308-8477
Mailing Address - Street 1:4020 N MACARTHUR BLVD
Mailing Address - Street 2:#122-286
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 REGAL ROW
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-5200
Practice Address - Country:US
Practice Address - Phone:817-308-8477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1969261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center