Healthcare Provider Details

I. General information

NPI: 1659934370
Provider Name (Legal Business Name): ESTE MARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15667 88TH ST NE APT 210
OTSEGO MN
55330-2960
US

IV. Provider business mailing address

15667 88TH ST NE APT 210
OTSEGO MN
55330-2960
US

V. Phone/Fax

Practice location:
  • Phone: 718-598-0167
  • Fax:
Mailing address:
  • Phone: 718-598-0167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number71740
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: