Provider Demographics
NPI:1932344207
Name:CHAVEZ, MARISA (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:CHAVEZ
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 1:2400 MOUNT ZION PKWY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2500
Mailing Address - Country:US
Mailing Address - Phone:770-603-3634
Mailing Address - Fax:
Practice Address - Street 1:2400 MOUNT ZION PKWY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2500
Practice Address - Country:US
Practice Address - Phone:770-603-3634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106212207V00000X
GA066008207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003114009DMedicaid
GA003114009DMedicaid