Provider Demographics
NPI:1508862632
Name:MARIEB, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MARIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1256
Mailing Address - Fax:
Practice Address - Street 1:2313 WHITNEY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-1326
Practice Address - Country:US
Practice Address - Phone:203-916-5670
Practice Address - Fax:203-732-1470
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT28115207RC0000X
CT028115207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE86767Medicare UPIN