Healthcare Provider Details

I. General information

NPI: 1861635674
Provider Name (Legal Business Name): MARISSA J DEFREITAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

PO BOX 16960 DIVISION OF PEDIATRIC NEPHROLOGY, (M-714)
MIAMI FL
33101-6960
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-6726
  • Fax:
Mailing address:
  • Phone: 954-599-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME123124
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberME123124
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: