Provider Demographics
NPI:1932173044
Name:MARROQUIN, GERARD ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:ANTHONY
Last Name:MARROQUIN
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:PO BOX 22010
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-2010
Mailing Address - Country:US
Mailing Address - Phone:254-751-4303
Mailing Address - Fax:254-751-4024
Practice Address - Street 1:318 RICHLAND WEST CIR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7919
Practice Address - Country:US
Practice Address - Phone:254-537-0200
Practice Address - Fax:254-537-0201
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123477504Medicaid
TX88X542OtherBCBS
00N59XOtherBCBS TEXAS
TX123477504Medicaid
TX88X542Medicare ID - Type Unspecified
88X542Medicare PIN
080072972Medicare PIN
TXB113312Medicare PIN
00N59XMedicare PIN