Healthcare Provider Details

I. General information

NPI: 1326422908
Provider Name (Legal Business Name): MARISA ELIAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISA CHANG M.D.

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E 2ND ST
ROYAL OAK MI
48067-2694
US

IV. Provider business mailing address

110 E 2ND ST
ROYAL OAK MI
48067-2694
US

V. Phone/Fax

Practice location:
  • Phone: 248-546-2110
  • Fax:
Mailing address:
  • Phone: 248-546-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301108364
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: