MEDICARE: DR. JOHN ROBERT MARIETTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	E8690	TX

General Provider Information

NPI Number	:	1114033693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ROBERT MARIETTA MD

Provider Business Mailing Address
First Line	:	6101 BALCONES DR STE 300
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-4277
Country	:	US
Telephone Number	:	512-482-0045
Fax Number	:	512-476-9892

Provider Business Practice Location Address
First Line	:	6101 BALCONES DR STE 300
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-4277
Country	:	US
Telephone Number	:	512-482-0045
Fax Number	:	512-476-9892

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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