Healthcare Provider Details

I. General information

NPI: 1235109455
Provider Name (Legal Business Name): MARCO BURENKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 W COCOA BCH CSWY STE 203
COCA BEACH FL
32931
US

IV. Provider business mailing address

657 BREVARD AVE
COCOA FL
32922
US

V. Phone/Fax

Practice location:
  • Phone: 321-799-7123
  • Fax:
Mailing address:
  • Phone: 321-632-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number51687
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: