Healthcare Provider Details

I. General information

NPI: 1073531505
Provider Name (Legal Business Name): MARISSA CHRISTINE STOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 PATIENTS FIRST DR
WASHINGTON MO
63090-4700
US

IV. Provider business mailing address

901 PATIENTS FIRST DR
WASHINGTON MO
63090-4700
US

V. Phone/Fax

Practice location:
  • Phone: 636-231-3690
  • Fax: 636-231-3693
Mailing address:
  • Phone: 636-231-3690
  • Fax: 636-231-3693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2004007508
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2004007508
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2004007508
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: