Healthcare Provider Details

I. General information

NPI: 1972544062
Provider Name (Legal Business Name): MARISSA B. WEISS-BAKER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LEXINGTON RD STE 200
WOOLWICH TOWNSHIP NJ
08085-1278
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 856-241-2111
  • Fax: 856-241-2243
Mailing address:
  • Phone: 856-686-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMB71280
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: