Provider Demographics
NPI:1992338586
Name:JEREZ, MARCO RODRIGO (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:RODRIGO
Last Name:JEREZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 W SAM HOUSTON PKWY N
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2626 W SAM HOUSTON PKWY N
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-1606
Practice Address - Country:US
Practice Address - Phone:713-996-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1286893225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist