Provider Demographics
NPI:1881766962
Name:MARQUARDT, WALT (MD)
Entity type:Individual
Prefix:
First Name:WALT
Middle Name:
Last Name:MARQUARDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HURLEY WAY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3216
Mailing Address - Country:US
Mailing Address - Phone:916-564-3040
Mailing Address - Fax:916-564-3065
Practice Address - Street 1:3941 J STREET
Practice Address - Street 2:SUITE 260
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3633
Practice Address - Country:US
Practice Address - Phone:916-736-2323
Practice Address - Fax:916-736-0620
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59664207RC0000X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G596640Medicaid
CAGR0068230Medicaid
CAZZZ47675ZOtherBLUE SHIELD
CAGR0068231Medicaid
CAZZZ47676ZOtherBLUE SHIELD
CAGR0068235Medicaid
CA060033947OtherRAILROAD MEDICARE
CAGR0068233Medicaid
CAGR006823BMedicaid
CAZZZ62306ZOtherBLUE SHIELD
CAGR0068232Medicaid
CAZZZ47673ZOtherBLUE SHIELD
CAZZZ28052ZMedicare PIN
CA060033947OtherRAILROAD MEDICARE
A53515Medicare UPIN
CA00G596640Medicare ID - Type Unspecified
CAGR006823BMedicaid
CAZZZ17828ZMedicare PIN
CAZZZ00967ZMedicare PIN
CAZZZ00966ZMedicare PIN