Basic Information
| Provider Information | |||||||||
| NPI: | 1215989538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | MARITA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 LUSK ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636293 | ||||||||
| FaxNumber: | 6077636717 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 ARCH ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636075 | ||||||||
| FaxNumber: | 6077635234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 187655 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01493970 | 05 | NY | MEDICAID |