Provider Demographics
NPI:1437178340
Name:FELICIANO, MARISA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:
Last Name:FELICIANO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PEACHTREE ST NE
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2247
Mailing Address - Country:US
Mailing Address - Phone:404-686-8126
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2247
Practice Address - Country:US
Practice Address - Phone:404-686-8126
Practice Address - Fax:404-686-4785
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001322152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U70853Medicare UPIN
GA41ZCFDPMedicare ID - Type Unspecified