Basic Information
| Provider Information | |||||||||
| NPI: | 1043229743 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COULURIS | ||||||||
| FirstName: | MARISA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 917770 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328910001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139742201 | ||||||||
| FaxNumber: | 8139742812 | ||||||||
| Practice Location | |||||||||
| Address1: | 12901 BRUCE B DOWNS BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132598700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS9261 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 48177 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 270226600 | 05 | FL | MEDICAID |