Basic Information
| Provider Information | |||||||||
| NPI: | 1619974839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARCIALES | ||||||||
| FirstName: | WERTHER | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 CORTEZ RD W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342103142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413575550 | ||||||||
| FaxNumber: | 9417927152 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 CORTEZ RD W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342103142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413575550 | ||||||||
| FaxNumber: | 9417927152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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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 | 207R00000X | ME70054 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32220 | 01 | FL | BLUE CROSS BLUE SHIELD FL | OTHER | 251048100 | 05 | FL | MEDICAID |