Provider Demographics
NPI:1053417642
Name:MARITA FALLORINA LLC FALLORINA MARITA M SINGLE MEMBER
Entity type:Organization
Organization Name:MARITA FALLORINA LLC FALLORINA MARITA M SINGLE MEMBER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARITA
Authorized Official - Middle Name:MAPUA
Authorized Official - Last Name:FALLORINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-322-6847
Mailing Address - Street 1:1 CATHERINE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-3001
Mailing Address - Country:US
Mailing Address - Phone:302-322-6847
Mailing Address - Fax:302-322-6847
Practice Address - Street 1:1 CATHERINE ST
Practice Address - Street 2:STE 1
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-3001
Practice Address - Country:US
Practice Address - Phone:302-322-6847
Practice Address - Fax:302-322-6909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10000755207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE48401Medicaid
DE123610Medicare ID - Type Unspecified
DE48401Medicaid