Provider Demographics
NPI:1063404747
Name:MARQUE, MELVIN JOSEPH III (MD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:JOSEPH
Last Name:MARQUE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5203
Mailing Address - Country:US
Mailing Address - Phone:337-990-8000
Mailing Address - Fax:
Practice Address - Street 1:1905 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5203
Practice Address - Country:US
Practice Address - Phone:337-990-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024321207PE0004X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1109975Medicaid
LAP00980762OtherMCARE RR
LA1109975Medicaid
LA4E030DU45Medicare PIN
LA4E030CN33Medicare PIN
TXH53177Medicare UPIN
LA1109975Medicaid