Provider Demographics
NPI:1144560160
Name:MARRERO VELIS, EDUARDO ANTONIO
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:ANTONIO
Last Name:MARRERO VELIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:
Practice Address - Street 1:815 E 15TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1631
Practice Address - Country:US
Practice Address - Phone:520-364-5437
Practice Address - Fax:520-364-4261
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52572208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ171732Medicaid