Provider Demographics
NPI:1497940977
Name:MARISHA CHILCOTT MD INC
Entity Type:Organization
Organization Name:MARISHA CHILCOTT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-542-1933
Mailing Address - Street 1:1144 SONOMA AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4812
Mailing Address - Country:US
Mailing Address - Phone:707-542-1933
Mailing Address - Fax:707-542-6227
Practice Address - Street 1:1144 SONOMA AVE STE 104
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4812
Practice Address - Country:US
Practice Address - Phone:707-542-1933
Practice Address - Fax:707-542-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88901207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI50886Medicare UPIN