Healthcare Provider Details

I. General information

NPI: 1053231241
Provider Name (Legal Business Name): MICHAEL MARROQUIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9990 ALABAMA ST
REDLANDS CA
92374-2066
US

IV. Provider business mailing address

3577 RUBIDOUX BLVD
JURUPA VALLEY CA
92509-4459
US

V. Phone/Fax

Practice location:
  • Phone: 909-372-0280
  • Fax:
Mailing address:
  • Phone: 951-500-5605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: