Healthcare Provider Details

I. General information

NPI: 1679548994
Provider Name (Legal Business Name): JILL A MARIANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 FIRST COLONIAL RD STE 204
VIRGINIA BEACH VA
23451
US

IV. Provider business mailing address

844 FIRST COLONIAL RD STE 204
VIRGINIA BEACH VA
23451
US

V. Phone/Fax

Practice location:
  • Phone: 757-491-7337
  • Fax: 757-491-2233
Mailing address:
  • Phone: 757-491-7337
  • Fax: 757-491-2233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101231176
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: