Provider Demographics
NPI:1801941125
Name:DOUGLAS MARIRA, MD, PC
Entity type:Organization
Organization Name:DOUGLAS MARIRA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-692-1181
Mailing Address - Street 1:PO BOX 24359
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31403-4359
Mailing Address - Country:US
Mailing Address - Phone:912-692-1181
Mailing Address - Fax:912-692-1184
Practice Address - Street 1:5354 REYNOLDS ST
Practice Address - Street 2:SUITE 328
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6007
Practice Address - Country:US
Practice Address - Phone:912-692-1181
Practice Address - Fax:912-692-1184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029284208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000398549GMedicaid
GA000398549GMedicaid