Provider Demographics
NPI:1225153356
Name:MARISSA T SANTOS, MD PC
Entity Type:Organization
Organization Name:MARISSA T SANTOS, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:T
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-255-2333
Mailing Address - Street 1:6911 ROOSEVELT AVE # B
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6911 ROOSEVELT AVE # B
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2933
Practice Address - Country:US
Practice Address - Phone:718-478-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07079GOtherGHI-MEDICARE
NY1531786OtherUHC
NY158042OtherVYTRA
NY84798OtherGHI HMO
NYP384086OtherOXFORD
NY113380648SA01OtherCARE PLUS
NY198043B27OtherHEALTH FIRST
NY8433171OtherCIGNA
NY040426017706OtherFIDELIS
NY166AF1OtherEMPIRE BCBS
NY172917OtherELDERPLAN
NY2592255OtherGHI
NY5816203OtherAETNA (HMO)
NY198043OtherHIP
NY1P1113OtherHEALTHNET
NY100153178601OtherUHC (HMO)
NY11P8501OtherNY PRESBYTERIAN
NYSM8043OtherAFFINITY
07079GOtherGHI-MEDICARE
NY5816203OtherAETNA (HMO)
NY07079GMedicare PIN