Provider Demographics
NPI:1639188220
Name:NORMAN, MARQUITA S (MD)
Entity Type:Individual
Prefix:
First Name:MARQUITA
Middle Name:S
Last Name:NORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARQUITA
Other - Middle Name:N
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 MEDICAL CENTER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1089
Mailing Address - Country:US
Mailing Address - Phone:336-716-4629
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1089
Practice Address - Country:US
Practice Address - Phone:336-716-4629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-02319207P00000X
MI4301082695207P00000X
ALMD.28433207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009914112Medicaid
MI491915310Medicaid
AL1639188220OtherTRICARE SOUTH
AL515-45665OtherBCBS
MH082695OtherCOMMERCIAL-COMMERCIAL NUMBER
700H262530OtherBLUE CROSS-BLUE CROSS
MH082695OtherCHAMPUS-CHAMPUS
AL110789Medicaid
AL510I930094Medicare PIN
I62865Medicare UPIN
MI491915310Medicaid
ALP00767942Medicare PIN
AL1639188220OtherTRICARE SOUTH
0H26253174Medicare ID - Type Unspecified