Provider Demographics
NPI:1982195889
Name:HABERLACH, MARISSA JEAN (DO)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JEAN
Last Name:HABERLACH
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:PO BOX 245057
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5057
Mailing Address - Country:US
Mailing Address - Phone:520-626-7233
Mailing Address - Fax:
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-5057
Practice Address - Country:US
Practice Address - Phone:520-694-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR2955207P00000X
CA19073207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine