Healthcare Provider Details

I. General information

NPI: 1568476455
Provider Name (Legal Business Name): MARYANNE REGINA CHRISANT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYANNE REGINA KICHUK MD

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE
BRONX NY
10467-2403
US

IV. Provider business mailing address

111 E 210TH ST
BRONX NY
10467-2401
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4321
  • Fax:
Mailing address:
  • Phone: 718-920-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME107102
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number177066
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: