Basic Information
| Provider Information | |||||||||
| NPI: | 1144560160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARRERO VELIS | ||||||||
| FirstName: | EDUARDO | ||||||||
| MiddleName: | ANTONIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 F AVE | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203646852 | ||||||||
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| Practice Location | |||||||||
| Address1: | 815 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856071631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203645437 | ||||||||
| FaxNumber: | 5203644261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2013 | ||||||||
| LastUpdateDate: | 11/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 52572 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 171732 | 05 | AZ | MEDICAID |