Provider Demographics
NPI:1457422529
Name:MARIETTA, MIA H (MD)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:H
Last Name:MARIETTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 2550
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2653
Mailing Address - Country:US
Mailing Address - Phone:207-373-1707
Mailing Address - Fax:207-373-1467
Practice Address - Street 1:121 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 2550
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2653
Practice Address - Country:US
Practice Address - Phone:207-373-1707
Practice Address - Fax:207-373-1467
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC-06-1101208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002612901Medicare PIN