Provider Demographics
NPI:1548737281
Name:ZODIKOFF, MARISSA BROOKE LEAVITT (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:BROOKE LEAVITT
Last Name:ZODIKOFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-657-6425
Mailing Address - Fax:617-421-2236
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7865363A00000X
NY022873-1208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant