Healthcare Provider Details

I. General information

NPI: 1295477396
Provider Name (Legal Business Name): MARISA LYNN DELGADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 BROOKSIDE PKWY STE 104
ALPHARETTA GA
30022-4457
US

IV. Provider business mailing address

485 STERLING ST NE
ATLANTA GA
30307-2007
US

V. Phone/Fax

Practice location:
  • Phone: 404-255-0621
  • Fax:
Mailing address:
  • Phone: 678-983-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number113859
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: