Provider Demographics
NPI:1104819846
Name:RILEY, MARISTELLA (MD)
Entity type:Individual
Prefix:DR
First Name:MARISTELLA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARISTELLA
Other - Middle Name:
Other - Last Name:RILEY DAVILA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:886 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6514
Mailing Address - Country:US
Mailing Address - Phone:678-432-1119
Mailing Address - Fax:678-432-1169
Practice Address - Street 1:886 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6514
Practice Address - Country:US
Practice Address - Phone:678-432-1119
Practice Address - Fax:678-432-1169
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG31130Medicare UPIN
GA06BDGXXMedicare ID - Type UnspecifiedPROVIDER #