=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275847519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRIDANI CHOUDHURY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2010
-----------------------------------------------------
Last Update Date | 11/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4061 OLD PESHTIGO RD
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-3887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-732-8130
-----------------------------------------------------
Fax | 715-732-8131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-0018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-732-7286
-----------------------------------------------------
Fax | 715-735-4616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4301097036
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 60009-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------