Healthcare Provider Details

I. General information

NPI: 1053417642
Provider Name (Legal Business Name): MARITA FALLORINA LLC FALLORINA MARITA M SINGLE MEMBER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CATHERINE ST STE 1
NEW CASTLE DE
19720-3001
US

IV. Provider business mailing address

1 CATHERINE ST STE 1
NEW CASTLE DE
19720-3001
US

V. Phone/Fax

Practice location:
  • Phone: 302-322-6847
  • Fax: 302-322-6909
Mailing address:
  • Phone: 302-322-6847
  • Fax: 302-322-6847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10000755
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC10000755
License Number StateDE

VIII. Authorized Official

Name: MARITA MAPUA FALLORINA
Title or Position: PHYSICIAN
Credential: MD
Phone: 302-322-6847