Provider Demographics
NPI:1487643730
Name:BATAYOLA, MARISSA C (MD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:C
Last Name:BATAYOLA
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 1:1504 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9779
Mailing Address - Country:US
Mailing Address - Phone:815-842-2893
Mailing Address - Fax:815-844-5960
Practice Address - Street 1:1504 W REYNOLDS ST
Practice Address - Street 2:SUITE C
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9779
Practice Address - Country:US
Practice Address - Phone:815-842-2893
Practice Address - Fax:815-844-5960
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH06955Medicare UPIN
IL203033Medicare ID - Type Unspecified