Provider Demographics
NPI:1912288515
Name:CASAMALHUAPA, MARTHA LISSETT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:LISSETT
Last Name:CASAMALHUAPA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14130 NOBLEWOOD PLZ
Mailing Address - Street 2:SUITE 306
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1464
Mailing Address - Country:US
Mailing Address - Phone:703-485-0470
Mailing Address - Fax:
Practice Address - Street 1:14130 NOBLEWOOD PLZ
Practice Address - Street 2:SUITE 306
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1464
Practice Address - Country:US
Practice Address - Phone:703-485-0470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2014-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256199208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics