Healthcare Provider Details

I. General information

NPI: 1265550677
Provider Name (Legal Business Name): MARISSA TAGABAN CALUYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE PEDIATRICS ADMINISTRATION
COLTON CA
92324-1819
US

IV. Provider business mailing address

400 N PEPPER AVE PEDIATRICS ADMINISTRATION
COLTON CA
92324-1819
US

V. Phone/Fax

Practice location:
  • Phone: 855-422-8029
  • Fax: 909-580-1438
Mailing address:
  • Phone: 855-422-8029
  • Fax: 909-580-1438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC51278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: