Provider Demographics
NPI:1174549299
Name:MARIBAO, RHETTA FAYE C (DO)
Entity type:Individual
Prefix:
First Name:RHETTA FAYE
Middle Name:C
Last Name:MARIBAO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:909 BALLANTYNE RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1217
Mailing Address - Country:US
Mailing Address - Phone:586-726-0340
Mailing Address - Fax:586-254-3872
Practice Address - Street 1:21600 HARPER AVENUE
Practice Address - Street 2:100
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-726-0340
Practice Address - Fax:586-254-3872
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101014672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0855011954OtherBC
MI0855011954OtherBC
MIP20260001Medicare PIN