Provider Demographics
NPI:1023540671
Name:WIRTH, MARIKO V
Entity Type:Individual
Prefix:
First Name:MARIKO
Middle Name:V
Last Name:WIRTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063
Mailing Address - Country:US
Mailing Address - Phone:610-565-9642
Mailing Address - Fax:
Practice Address - Street 1:32 E FRONT ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:610-565-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK001220171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist