Provider Demographics
NPI:1629076039
Name:MARRESE, ROXY JR (MD)
Entity Type:Individual
Prefix:
First Name:ROXY
Middle Name:
Last Name:MARRESE
Suffix:JR
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 1:3911 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4910
Mailing Address - Country:US
Mailing Address - Phone:386-258-4840
Mailing Address - Fax:386-255-0140
Practice Address - Street 1:201 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2724
Practice Address - Country:US
Practice Address - Phone:386-258-4840
Practice Address - Fax:386-255-0140
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0025420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
78220ZMedicare ID - Type Unspecified
D82547Medicare UPIN