Provider Demographics
NPI:1619274743
Name:CHAVEZ, MARCO ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCO
Middle Name:ANTONIO
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3914 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3003
Mailing Address - Country:US
Mailing Address - Phone:619-344-7036
Mailing Address - Fax:619-291-4426
Practice Address - Street 1:3914 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3003
Practice Address - Country:US
Practice Address - Phone:619-344-7036
Practice Address - Fax:619-291-4426
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2013-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1159322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA115932OtherSTATE LICENSE