Provider Demographics
NPI:1659520823
Name:DUQUE, MARVIN ANTONIO PORFIRO SISON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN ANTONIO
Middle Name:PORFIRO SISON
Last Name:DUQUE
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 1:4901 LANG AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4495
Mailing Address - Country:US
Mailing Address - Phone:505-842-8171
Mailing Address - Fax:
Practice Address - Street 1:4901 LANG AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4495
Practice Address - Country:US
Practice Address - Phone:505-842-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN016621A208M00000X
MA242096207RH0003X
NMMD2016-0099207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM76806057Medicaid
IN200934840Medicaid
IN200934840Medicaid
NM76806057Medicaid
NM48200YMKSMedicare PIN