Provider Demographics
NPI:1679828685
Name:MARQUEZ, MARIVIAN PANTINO
Entity Type:Individual
Prefix:
First Name:MARIVIAN
Middle Name:PANTINO
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 SAWGRASS CORPORATE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2859
Mailing Address - Country:US
Mailing Address - Phone:954-332-4445
Mailing Address - Fax:866-422-6431
Practice Address - Street 1:1564 KINGSLEY AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4521
Practice Address - Country:US
Practice Address - Phone:904-644-8911
Practice Address - Fax:904-644-7120
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30891225100000X
NY0347431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist