Healthcare Provider Details

I. General information

NPI: 1003084286
Provider Name (Legal Business Name): MARCOS ITAMAR CORDOBA MUNOZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARCOS ITAMAR MUNOZ M.D.

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE MATERNAL FETAL MEDICINE DEPT
GRAND RAPIDS MI
49503-2515
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3681
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number036135913
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number4301090455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: