Provider Demographics
NPI:1073809158
Name:AGESILAS, MARIELIE HEIDI (MD)
Entity Type:Individual
Prefix:MISS
First Name:MARIELIE
Middle Name:HEIDI
Last Name:AGESILAS
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 1:601 W. MAPLE
Mailing Address - Street 2:STE 102
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764
Mailing Address - Country:US
Mailing Address - Phone:479-750-6585
Mailing Address - Fax:479-872-0040
Practice Address - Street 1:1125 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1908
Practice Address - Country:US
Practice Address - Phone:479-521-8260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-8365207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine