Healthcare Provider Details

I. General information

NPI: 1740472646
Provider Name (Legal Business Name): MARICEL LILIAN RIDELLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 THIMBLE SHOALS BLVD BUILDING 300A
NEWPORT NEWS VA
23606
US

IV. Provider business mailing address

860 OMNI BLVD SUITE 303
NEWPORT VA
23662-1027
US

V. Phone/Fax

Practice location:
  • Phone: 757-595-4300
  • Fax: 757-591-9297
Mailing address:
  • Phone: 757-232-8769
  • Fax: 757-232-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP1-0027842
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA110936
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0101252641
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: