Healthcare Provider Details

I. General information

NPI: 1124088331
Provider Name (Legal Business Name): MARION LYNN LUQUE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 E. WINDING CREEK DRIVE
EAGLE ID
83616-6566
US

IV. Provider business mailing address

502 W TWO RIVERS DR
EAGLE ID
83616-7121
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-8887
  • Fax: 208-938-8897
Mailing address:
  • Phone: 208-599-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM8345
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: