Provider Demographics
NPI:1639350416
Name:IGNACIO, MIRELLE MARQUEZ (MD)
Entity Type:Individual
Prefix:
First Name:MIRELLE
Middle Name:MARQUEZ
Last Name:IGNACIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIRELLE
Other - Middle Name:ANN
Other - Last Name:MARQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:16465 SIERRA LAKES PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1242
Mailing Address - Country:US
Mailing Address - Phone:909-429-2864
Mailing Address - Fax:
Practice Address - Street 1:7777 MILLIKEN AVE STE 240
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6781
Practice Address - Country:US
Practice Address - Phone:909-429-2864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA131075207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine