Provider Demographics
NPI:1568476455
Name:CHRISANT, MARYANNE REGINA (MD)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:REGINA
Last Name:CHRISANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYANNE
Other - Middle Name:REGINA
Other - Last Name:KICHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:1150 N 35TH AVE STE 490
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5423
Practice Address - Country:US
Practice Address - Phone:954-265-3437
Practice Address - Fax:954-265-3731
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1071022080P0202X, 2080P0202X
PAMD4198542080P0202X
VA01012420292080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002152100Medicaid
NJ5999707Medicaid
NJ5999707Medicaid