Healthcare Provider Details

I. General information

NPI: 1881678340
Provider Name (Legal Business Name): IVAN F MARRERO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 CALLE PAVIA PAVIA MEDICAL PLAZA SUITE 208
SANTURCE PR
00909-2239
US

IV. Provider business mailing address

611 CALLE PAVIA PAVIA MEDICAL PLAZA SUITE 208
SANTURCE PR
00909-2239
US

V. Phone/Fax

Practice location:
  • Phone: 787-268-3200
  • Fax: 787-268-4045
Mailing address:
  • Phone: 787-268-3200
  • Fax: 787-268-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number653
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: