Provider Demographics
NPI:1710507199
Name:DELISO, MARISA AMANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:AMANDA
Last Name:DELISO
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 1:12970 174TH PL N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-5235
Mailing Address - Country:US
Mailing Address - Phone:561-401-3774
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program