Provider Demographics
NPI:1619023876
Name:CHUA, MARIETTA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIETTA
Middle Name:M
Last Name:CHUA
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 1:4 SWEET GUM LN
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-4207
Mailing Address - Country:US
Mailing Address - Phone:843-363-2599
Mailing Address - Fax:
Practice Address - Street 1:4 SWEET GUM LN
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-4207
Practice Address - Country:US
Practice Address - Phone:843-363-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF77222084P0804X
GA0569852084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPOOOD74Q6Medicaid
TXPOOOD74Q6Medicaid
TXCI4480Medicare UPIN