Healthcare Provider Details

I. General information

NPI: 1770997421
Provider Name (Legal Business Name): MARANDA RECORD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37822 US HIGHWAY 18
PRAIRIE DU CHIEN WI
53821-8416
US

IV. Provider business mailing address

37822 US HIGHWAY 18
PRAIRIE DU CHIEN WI
53821-8416
US

V. Phone/Fax

Practice location:
  • Phone: 608-357-2500
  • Fax:
Mailing address:
  • Phone: 608-357-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME130179
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD22244
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: