=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437224623
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUISA PORTAL MARSTELLER MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2221 EDWARD HOLLAND DR
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23230-2518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-354-2696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 THOMAS CARTWRIGHT
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-8904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-345-5652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 0101041131
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------