Healthcare Provider Details

I. General information

NPI: 1861733313
Provider Name (Legal Business Name): MICHELLE NICOLE MARIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE NICOLE VAZQUEZ MD

II. Dates (important events)

Enumeration Date: 03/08/2013
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 S SEACREST BLVD
BOYNTON BEACH FL
33435-7969
US

IV. Provider business mailing address

3003 SHAUGHNESSY DR
WELLINGTON FL
33414-3400
US

V. Phone/Fax

Practice location:
  • Phone: 561-737-7733
  • Fax:
Mailing address:
  • Phone: 646-734-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number265109
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberME153065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: