Provider Demographics
NPI:1467500470
Name:LIWAG, MARIA MARISSA DE LEON (MD)
Entity Type:Individual
Prefix:
First Name:MARIA MARISSA
Middle Name:DE LEON
Last Name:LIWAG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA MARISSA
Other - Middle Name:ANUDDIN
Other - Last Name:DE LEON-LIWAG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4125 BANGS AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8713
Mailing Address - Country:US
Mailing Address - Phone:209-551-3174
Mailing Address - Fax:209-557-1685
Practice Address - Street 1:4125 BANGS AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8713
Practice Address - Country:US
Practice Address - Phone:209-551-3174
Practice Address - Fax:209-557-1685
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89974208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A899740Medicaid