Healthcare Provider Details

I. General information

NPI: 1225097991
Provider Name (Legal Business Name): COREY H MARCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 AVOCADO AVE
EL CAJON CA
92020-4604
US

IV. Provider business mailing address

280 AVOCADO AVE
EL CAJON CA
92020-4604
US

V. Phone/Fax

Practice location:
  • Phone: 619-442-0424
  • Fax: 619-442-8517
Mailing address:
  • Phone: 619-442-0424
  • Fax: 619-442-8517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA22907
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA22907
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: