Provider Demographics
NPI:1568477982
Name:MARIETTA, CHANDLER W (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDLER
Middle Name:W
Last Name:MARIETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:85 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03246-3113
Mailing Address - Country:US
Mailing Address - Phone:603-524-7402
Mailing Address - Fax:603-524-0945
Practice Address - Street 1:85 SPRING STREET
Practice Address - Street 2:ENT ASSOCIATES OF NEW HAMPSHIRE
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3113
Practice Address - Country:US
Practice Address - Phone:603-524-7402
Practice Address - Fax:603-524-0945
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHT0557207Y00000X
MN104228207Y00000X
NH15543207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH15543OtherLICENSE
NH3077638Medicaid