Provider Demographics
NPI:1831184134
Name:HADDAD, MARISA LOUISE (DPM)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LOUISE
Last Name:HADDAD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:HADDAD
Other - Last Name:SEKOSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 8837
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-0130
Mailing Address - Country:US
Mailing Address - Phone:602-938-8400
Mailing Address - Fax:602-938-8401
Practice Address - Street 1:3201 W PEORIA AVE
Practice Address - Street 2:STE B307
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4608
Practice Address - Country:US
Practice Address - Phone:602-938-8400
Practice Address - Fax:602-938-8401
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2013-08-07
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-17
Provider Licenses
StateLicense IDTaxonomies
AZ0473213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ398322Medicaid
AZZ67545Medicare PIN
AZ398322Medicaid