Provider Demographics
NPI:1619498706
Name:CIAMACCA, MARISA LYNN (OD, MS)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LYNN
Last Name:CIAMACCA
Suffix:
Gender:F
Credentials:OD, MS
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2591 WEXFORD BAYNE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SEWICKLEY
Mailing Address - State:PA
Mailing Address - Zip Code:15143-8676
Mailing Address - Country:US
Mailing Address - Phone:724-933-5588
Mailing Address - Fax:724-933-6051
Practice Address - Street 1:2591 WEXFORD BAYNE RD STE 104
Practice Address - Street 2:
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143
Practice Address - Country:US
Practice Address - Phone:724-933-5588
Practice Address - Fax:724-933-6051
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDTA2583152W00000X
PAOEG003437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103523475Medicaid