Provider Demographics
NPI:1144297516
Name:FERNANDEZ KIEMELE, MARISSA CASTRO (MD)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:CASTRO
Last Name:FERNANDEZ KIEMELE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARISSA
Other - Middle Name:CASTRO
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:50 STANIFORD ST FL 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2506
Mailing Address - Country:US
Mailing Address - Phone:617-724-6610
Mailing Address - Fax:603-929-1196
Practice Address - Street 1:50 STANIFORD ST FL 9
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2506
Practice Address - Country:US
Practice Address - Phone:617-724-6610
Practice Address - Fax:603-929-1196
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA292453207Q00000X
NH18726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3112129Medicaid
WA8268922Medicaid
WA8949411OtherSTATE CRIME VICTIMS COMPENSATION
WA0242574OtherSTATE L&I
WA8268922Medicaid
WA8949411OtherSTATE CRIME VICTIMS COMPENSATION
8851323Medicare ID - Type Unspecified
WAG8877697Medicare PIN