Healthcare Provider Details

I. General information

NPI: 1942837661
Provider Name (Legal Business Name): MARIELLE SAMSON DACLAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR FL 7
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

111 E 18TH ST APT 416
NORFOLK VA
23517-0020
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-3447
  • Fax: 757-388-5340
Mailing address:
  • Phone: 609-334-9158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License NumberMT229392
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2025-00616
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number0101283199
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: