Provider Demographics
NPI:1073531505
Name:STOCK, MARISSA CHRISTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:CHRISTINE
Last Name:STOCK
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-231-3690
Mailing Address - Fax:636-231-3693
Practice Address - Street 1:901 PATIENTS FIRST DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4700
Practice Address - Country:US
Practice Address - Phone:636-231-3690
Practice Address - Fax:636-231-3693
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040075082080N0001X, 2080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206232407Medicaid
MO206232407Medicaid
939150381Medicare PIN
IL$$$$$$$$$Medicaid
939152943Medicare PIN