Provider Demographics
NPI:1942837661
Name:DACLAN, MARIELLE SAMSON (MD)
Entity type:Individual
Prefix:
First Name:MARIELLE
Middle Name:SAMSON
Last Name:DACLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 18TH ST APT 416
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-0020
Mailing Address - Country:US
Mailing Address - Phone:609-334-9158
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR FL 7
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3447
Practice Address - Fax:757-388-5340
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT229392207PH0002X
NC2025-00616207RH0002X
390200000X
VA0101283199207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program