Provider Demographics
NPI:1972784486
Name:SIMARD, MARISSA LYNNE (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LYNNE
Last Name:SIMARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:LYNNE
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-242-4162
Mailing Address - Fax:541-345-2358
Practice Address - Street 1:920 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 100A
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6024
Practice Address - Country:US
Practice Address - Phone:541-242-4162
Practice Address - Fax:541-345-2358
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1619862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972784486OtherNPI
OR500659534Medicaid
R170704Medicare PIN