Provider Demographics
NPI:1518148915
Name:CO, MARIDINE L (MD)
Entity Type:Individual
Prefix:
First Name:MARIDINE
Middle Name:L
Last Name:CO
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 1:6321 VIA SERENA DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-2661
Mailing Address - Country:US
Mailing Address - Phone:313-212-7680
Mailing Address - Fax:
Practice Address - Street 1:6321 VIA SERENA DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-2661
Practice Address - Country:US
Practice Address - Phone:313-212-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60230208000000X, 207RG0100X
TXQ8708207RG0100X, 2080P0206X
MI4301089612208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology