Provider Demographics
NPI:1093164873
Name:O'NEILL, MARISA (DO)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:BAUTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DRIVE
Mailing Address - Street 2:SUITE J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5320 ELLIOTT DRIVE
Practice Address - Street 2:SUITE 203
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-1700
Practice Address - Fax:734-887-8938
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101026448208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery