Provider Demographics
NPI:1538523717
Name:LUOMA, MARISSA JUSTINE (MD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:JUSTINE
Last Name:LUOMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-2617
Practice Address - Fax:317-278-2587
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01086200A2080C0008X, 208000000X
KYTP228208M00000X, 207R00000X
KY53909208000000X
KYR4128207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300052728Medicaid