Individual
MARISA FORMICA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
101 SAINT ANDREWS LN, GLEN COVE, NY 11542-2254
(516) 674-7631
Mailing address
101 SAINT ANDREWS LN, GLEN COVE, NY 11542-2254
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
280850
NY
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
280850
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
07/05/2011
Last updated
01/16/2026
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