Provider Demographics
NPI:1215989538
Name:POWELL, MARITA (DO)
Entity type:Individual
Prefix:
First Name:MARITA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 LUSK ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2541
Mailing Address - Country:US
Mailing Address - Phone:607-763-6293
Mailing Address - Fax:607-763-6717
Practice Address - Street 1:40 ARCH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2102
Practice Address - Country:US
Practice Address - Phone:607-763-6075
Practice Address - Fax:607-763-5234
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01493970Medicaid
NY01493970Medicaid
NYCC8166Medicare PIN