Healthcare Provider Details

I. General information

NPI: 1295185247
Provider Name (Legal Business Name): MARISSA SPINO-KEETON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W 11TH ST
INDIANAPOLIS IN
46202-4108
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-491-6000
  • Fax: 317-491-6534
Mailing address:
  • Phone: 317-963-9328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number02008087A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberDR.0071145
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: