Provider Demographics
NPI:1922031699
Name:MARQUEZ, JONATHAN P
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:MARQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 W KILBOURN AVE
Mailing Address - Street 2:STE 124
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1330
Mailing Address - Country:US
Mailing Address - Phone:414-291-2626
Mailing Address - Fax:414-291-2630
Practice Address - Street 1:1218 W KILBOURN AVE
Practice Address - Street 2:STE 124
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1330
Practice Address - Country:US
Practice Address - Phone:414-291-2626
Practice Address - Fax:414-291-2630
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49178-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34879100Medicaid
WI003101560Medicare PIN
WI34879100Medicaid