Provider Demographics
NPI:1922340074
Name:BACA, MARSHALL G JR (DO)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:G
Last Name:BACA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:704 W MONTERREY
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-2758
Mailing Address - Country:US
Mailing Address - Phone:520-370-8310
Mailing Address - Fax:
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2707
Practice Address - Country:US
Practice Address - Phone:915-545-7345
Practice Address - Fax:915-545-7338
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8422207P00000X
NMA-1877-15207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine