Provider Demographics
NPI:1710286448
Name:IP, MARISA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:
Last Name:IP
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 1:70 GLEN COVE ROAD, STE 301
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1726
Mailing Address - Country:US
Mailing Address - Phone:516-621-1502
Mailing Address - Fax:516-621-1162
Practice Address - Street 1:70 GLEN COVE RD STE 301
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1731
Practice Address - Country:US
Practice Address - Phone:516-621-1502
Practice Address - Fax:516-621-1162
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269700-1207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program