Provider Demographics
NPI:1093502015
Name:MONTEZUMA, MARCO AURELIO PETRONI
Entity type:Individual
Prefix:
First Name:MARCO AURELIO
Middle Name:PETRONI
Last Name:MONTEZUMA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22901 MILLCREEK BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5701
Mailing Address - Country:US
Mailing Address - Phone:407-748-6101
Mailing Address - Fax:
Practice Address - Street 1:22901 MILLCREEK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5701
Practice Address - Country:US
Practice Address - Phone:407-748-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program