Provider Demographics
NPI:1780029579
Name:STAHL, MARISA LAURA (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LAURA
Last Name:STAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:GALLANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13123 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7106
Practice Address - Country:US
Practice Address - Phone:720-777-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00564442080P0206X, 2080P0206X
NC191774390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program