Provider Demographics
NPI:1750426862
Name:MARIANO-MEJIA, MARISSA M (MD)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:M
Last Name:MARIANO-MEJIA
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 1:850 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5230
Mailing Address - Country:US
Mailing Address - Phone:909-421-9280
Mailing Address - Fax:909-421-9219
Practice Address - Street 1:850 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5230
Practice Address - Country:US
Practice Address - Phone:909-421-9280
Practice Address - Fax:909-421-9219
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA560232084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG80260Medicare ID - Type Unspecified