Provider Demographics
NPI:1164398608
Name:MARROQUIN, MANUEL IVAN (CDM)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:IVAN
Last Name:MARROQUIN
Suffix:
Gender:M
Credentials:CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12503 JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-2321
Mailing Address - Country:US
Mailing Address - Phone:949-836-0030
Mailing Address - Fax:
Practice Address - Street 1:6500 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4920
Practice Address - Country:US
Practice Address - Phone:424-315-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Single Specialty