Healthcare Provider Details

I. General information

NPI: 1144297516
Provider Name (Legal Business Name): MARISSA CASTRO FERNANDEZ KIEMELE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA CASTRO FERNANDEZ MD

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DR STE 200B
SAN RAFAEL CA
94903-5232
US

IV. Provider business mailing address

4000 CIVIC CENTER DR STE 200B
SAN RAFAEL CA
94903-5232
US

V. Phone/Fax

Practice location:
  • Phone: 415-492-3333
  • Fax: 415-492-3425
Mailing address:
  • Phone: 415-492-3333
  • Fax: 415-492-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number292453
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18726
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC192860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: