MEDICARE: DR. IVAN F MARRERO D.M.D.

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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	653	PR

General Provider Information

NPI Number	:	1881678340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVAN F MARRERO D.M.D.

Provider Business Mailing Address
First Line	:	611 CALLE PAVIA
Second Line	:	PAVIA MEDICAL PLAZA SUITE 208
City	:	SANTURCE
State	:	PR
Zip	:	00909-2239
Country	:	US
Telephone Number	:	787-268-3200
Fax Number	:	787-268-4045

Provider Business Practice Location Address
First Line	:	611 CALLE PAVIA
Second Line	:	PAVIA MEDICAL PLAZA SUITE 208
City	:	SANTURCE
State	:	PR
Zip	:	00909-2239
Country	:	US
Telephone Number	:	787-268-3200
Fax Number	:	787-268-4045

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	06/05/2012

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