Provider Demographics
NPI:1043539836
Name:ANDERSON, MARISSA LEA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:LEA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 1138
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3845
Mailing Address - Country:US
Mailing Address - Phone:312-942-7088
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 1138
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3845
Practice Address - Country:US
Practice Address - Phone:312-942-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA262804208600000X
GA83360208C00000X
TXBP10038035390200000X
IL036.161754208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program