Healthcare Provider Details

I. General information

NPI: 1902198096
Provider Name (Legal Business Name): EDWIN MARRERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-3601
  • Fax: 360-501-3648
Mailing address:
  • Phone: 360-729-1462
  • Fax: 360-729-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60460446
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD60460446
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: