Provider Demographics
NPI:1194904011
Name:VISITACION, MARIA CLARISSA LORETE (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA CLARISSA
Middle Name:LORETE
Last Name:VISITACION
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CLAIRE
Other - Middle Name:L
Other - Last Name:VISITACION
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:317 RESOURCE PKWY
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-8364
Mailing Address - Country:US
Mailing Address - Phone:678-975-7471
Mailing Address - Fax:678-975-7055
Practice Address - Street 1:317 RESOURCE PKWY
Practice Address - Street 2:SUITE 4B
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8364
Practice Address - Country:US
Practice Address - Phone:678-975-7471
Practice Address - Fax:678-975-7055
Is Sole Proprietor?:No
Enumeration Date:2007-10-27
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65434207Q00000X
OH57.013820390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program