Provider Demographics
NPI:1720183312
Name:LARGOZA, MARISSA N (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:N
Last Name:LARGOZA
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 1:4499 MEDICAL DR STE 191
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3774
Mailing Address - Country:US
Mailing Address - Phone:210-692-0831
Mailing Address - Fax:210-692-9202
Practice Address - Street 1:4499 MEDICAL DRIVE
Practice Address - Street 2:SUITE 191
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3774
Practice Address - Country:US
Practice Address - Phone:210-692-0404
Practice Address - Fax:210-692-9202
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0366207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140805601Medicaid
TX00145MMedicare ID - Type Unspecified
TX140805601Medicaid