Provider Demographics
NPI:1073622973
Name:VIERA, MARILYN (MSW DO)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:VIERA
Suffix:
Gender:F
Credentials:MSW DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 WOODS EDGE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5901
Mailing Address - Country:US
Mailing Address - Phone:517-349-3303
Mailing Address - Fax:517-349-4374
Practice Address - Street 1:2380 CEDAT ST
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842
Practice Address - Country:US
Practice Address - Phone:517-742-4922
Practice Address - Fax:517-699-2904
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C36097OtherTRAVELERS MEDICARE
MI113331464Medicaid
MI0C36097OtherBCBS MICHIGAN
MI0C360971062OtherMEDICARE
MI0C36097OtherTRAVELERS MEDICARE