Healthcare Provider Details

I. General information

NPI: 1568446128
Provider Name (Legal Business Name): JEAN MARIE RIQUELME MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N NINE MOUND RD
VERONA WI
53593-1032
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-845-9531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36042-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: