Provider Demographics
NPI:1659315828
Name:DEMARQUE, CHARLES DAN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAN
Last Name:DEMARQUE
Suffix:
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 1:2940 N O CONNOR RD STE 129
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-8808
Mailing Address - Country:US
Mailing Address - Phone:817-308-8477
Mailing Address - Fax:
Practice Address - Street 1:2940 N O CONNOR RD STE 129
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-8808
Practice Address - Country:US
Practice Address - Phone:817-308-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1969207P00000X
TNMD27491207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8J1336Medicare PIN
TNF63542Medicare UPIN