Provider Demographics
NPI:1285690313
Name:MARION, LORETTA M (DO)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:M
Last Name:MARION
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 ALLENS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-5010
Mailing Address - Country:US
Mailing Address - Phone:401-780-2511
Mailing Address - Fax:401-780-2565
Practice Address - Street 1:355 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-1928
Practice Address - Country:US
Practice Address - Phone:401-444-0570
Practice Address - Fax:401-444-0427
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007739L208000000X
SCDO37583208000000X
RIDO01075208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001592004Medicaid
G11677Medicare UPIN
PA001592004Medicaid