Provider Demographics
NPI:1053365478
Name:MARROQUIN, GLORIA (MD)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:MARROQUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-1122
Mailing Address - Country:US
Mailing Address - Phone:270-239-9355
Mailing Address - Fax:270-239-9356
Practice Address - Street 1:217 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42164-1122
Practice Address - Country:US
Practice Address - Phone:270-239-9355
Practice Address - Fax:270-239-9356
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM81632083P0901X, 207Q00000X
KY444642083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L25741Medicare PIN
FLI21846Medicare UPIN
TX8L25741Medicare UPIN