Provider Demographics
NPI:1104098169
Name:CEVASCO, MARISA (MD, MPH)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:CEVASCO
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-662-2050
Mailing Address - Fax:215-615-0829
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-2050
Practice Address - Fax:215-615-0829
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288226208G00000X
PAMD467275208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY288226OtherNYS LICENSE