Provider Demographics
NPI:1417049974
Name:CHRISTENSEN, MARISA D (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:D
Last Name:CHRISTENSEN
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 1:2 BOARS HEAD PL STE 110
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4678
Mailing Address - Country:US
Mailing Address - Phone:434-305-5955
Mailing Address - Fax:434-956-3133
Practice Address - Street 1:2 BOARS HEAD PL STE 110
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4678
Practice Address - Country:US
Practice Address - Phone:434-305-5955
Practice Address - Fax:434-956-3133
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010189951Medicaid
VAI36492Medicare UPIN
VA010059U92Medicare PIN
VAVV8615AMedicare UPIN