Provider Demographics
NPI:1629361506
Name:DE ALWIS, MARIE (MD)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:
Last Name:DE ALWIS
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 1:855 A AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5057
Mailing Address - Country:US
Mailing Address - Phone:319-368-9300
Mailing Address - Fax:319-368-5690
Practice Address - Street 1:855 A AVE NE
Practice Address - Street 2:SUITE 300
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5057
Practice Address - Country:US
Practice Address - Phone:319-368-9300
Practice Address - Fax:319-368-5690
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2014-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAMD41955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1629361506Medicaid
IA719260668Medicare PIN