Provider Demographics
NPI:1841239928
Name:MARQUEZ, MINDY LISA (MD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:LISA
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:LISA
Other - Last Name:SAMUELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2637 SHADELANDS DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2512
Mailing Address - Country:US
Mailing Address - Phone:925-948-8143
Mailing Address - Fax:
Practice Address - Street 1:3250 BEARD RD
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3406
Practice Address - Country:US
Practice Address - Phone:707-224-7944
Practice Address - Fax:707-224-5220
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045739208800000X
CAA106559208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8453318Medicaid
WAMD00045739OtherSTATE LICENSE NUMBER
WA0209119OtherLABOR AND INDUSTRY
WAP00340057OtherRAILROAD MEDICARE
WA8453318Medicaid
CABP699ZMedicare PIN
I53464Medicare UPIN