Provider Demographics
NPI:1598870859
Name:MARQUEZ, MA THERESA CHARISSE (MD)
Entity Type:Individual
Prefix:
First Name:MA THERESA
Middle Name:CHARISSE
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MA THERESA CHARISSE
Other - Middle Name:LAURON
Other - Last Name:DE LOS REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2615 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-2223
Mailing Address - Country:US
Mailing Address - Phone:603-286-1588
Mailing Address - Fax:
Practice Address - Street 1:2615 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2223
Practice Address - Country:US
Practice Address - Phone:558-229-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY7825877207RS0012X, 207R00000X
VT060-0004725390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3077020Medicaid