MEDICARE: CHARLES D. DEMARQUE, MD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	J1969	TX

General Provider Information

NPI Number	:	1649612110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES D. DEMARQUE, MD, PA

Provider Business Mailing Address
First Line	:	4020 N MACARTHUR BLVD
Second Line	:	SUITE 122-286
City	:	IRVING
State	:	TX
Zip	:	75038-6419
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4020 N MACARTHUR BLVD
Second Line	:	SUITE 122-286
City	:	IRVING
State	:	TX
Zip	:	75038-6419
Country	:	US
Telephone Number	:	817-308-8477
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	CHARLES D. DEMARQUE
Credential	:
Telephone Number	:	817-308-8477

Provider Enumeration Date	:	07/24/2013
Last Update Date	:	07/24/2013

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