Provider Demographics
NPI:1457616997
Name:BROWN, MARISSA LYN (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:LYN
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MARISSA
Other - Middle Name:LYN
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 TRAVELODGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020
Mailing Address - Country:US
Mailing Address - Phone:619-528-5000
Mailing Address - Fax:
Practice Address - Street 1:250 TRAVELODGE DRIVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:619-528-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207ZP0102X207V00000X
CAA142166207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR73474OtherTRAINING PERMIT