Basic Information
| Provider Information | |||||||||
| NPI: | 1023174414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARRA | ||||||||
| FirstName: | DIEGO | ||||||||
| MiddleName: | ESTEBAN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARCIA-MARRA | ||||||||
| OtherFirstName: | DIEGO | ||||||||
| OtherMiddleName: | ESTEBAN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5310 HARVEST HILL RD STE 290 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752305826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144200650 | ||||||||
| FaxNumber: | 2147360512 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 S HULEN ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761091528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179212838 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 10/13/2017 | ||||||||
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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 | 207N00000X | M5353 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | 207NS0135X | M5353 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207ND0101X | M5353 | TX | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.