Basic Information
| Provider Information | |||||||||
| NPI: | 1184671869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARQUEZ DE LEON | ||||||||
| FirstName: | JORGE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 W GOOD HOPE RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532092042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143523100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1640 E SUMNER ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530272684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626704000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 47555 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 48487 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1184671869 | 05 | WI | MEDICAID |