Provider Demographics
NPI:1093992679
Name:OMURTAG, MARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:
Last Name:OMURTAG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:DECASTRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:339 CONSORT DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4439
Mailing Address - Country:US
Mailing Address - Phone:636-386-9224
Mailing Address - Fax:636-200-4243
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:DEPT. OF ANESTHESIA
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-4687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-26
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002828207L00000X
MO2011013954207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO103250011Medicare PIN