Provider Demographics
NPI:1851587901
Name:BRANDT, MARISA STOLLER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:STOLLER
Last Name:BRANDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:ODETTE
Other - Last Name:STOLLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5472
Practice Address - Country:US
Practice Address - Phone:541-768-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-22
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101202207L00000X
ORMD152658207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500627460Medicaid
OR500627460Medicaid