Provider Demographics
NPI:1700801792
Name:DEATON, MARISA
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:DEATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 N TRADE ST
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:332 N TRADE ST
Practice Address - Street 2:SUITE 2000
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-1728
Practice Address - Country:US
Practice Address - Phone:704-302-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC51776207R00000X
NC2005-00652207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1700801792Medicaid
SCN00655Medicaid
NC5902169Medicaid
NC140JROtherBCBS
NC140JROtherBCBS
NC2047696Medicare PIN
NC5902169Medicaid
NC2047696AMedicare PIN
NC2047696BMedicare PIN