Provider Demographics
NPI:1952661191
Name:WATANABE, MARISELA (DO)
Entity Type:Individual
Prefix:
First Name:MARISELA
Middle Name:
Last Name:WATANABE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-3840
Mailing Address - Country:US
Mailing Address - Phone:305-576-1234
Mailing Address - Fax:305-571-2025
Practice Address - Street 1:3510 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-3840
Practice Address - Country:US
Practice Address - Phone:305-576-1234
Practice Address - Fax:305-571-2025
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-061193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine