Provider Demographics
NPI:1336119254
Name:MARSIDI, IRENE L (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:L
Last Name:MARSIDI
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 1:120 W WENGER RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322
Mailing Address - Country:US
Mailing Address - Phone:937-836-9921
Mailing Address - Fax:937-836-1298
Practice Address - Street 1:120 W WENGER RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322
Practice Address - Country:US
Practice Address - Phone:937-836-9921
Practice Address - Fax:937-836-1298
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-9887M208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1220092OtherUNITED HEALTHCARE
D49887OtherHUMANA
OH0568149Medicaid
OH000000011107OtherANTHEM BCBS
OH0568149Medicaid
MA0589252Medicare ID - Type Unspecified