Healthcare Provider Details

I. General information

NPI: 1275696866
Provider Name (Legal Business Name): THAO TRAN MARQUEZ MD,MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THAO PHUONG TRAN MD

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 7011B
CREVE COEUR MO
63141-8232
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6840
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2018-0703
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number2012029320
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number48381
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: