Provider Demographics
NPI:1174628895
Name:DURETTE, MARC R (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:R
Last Name:DURETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 N. CHIPPEWA DR
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-9503
Mailing Address - Country:US
Mailing Address - Phone:715-365-5256
Mailing Address - Fax:715-365-5258
Practice Address - Street 1:1630 CHIPPEWA DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-9503
Practice Address - Country:US
Practice Address - Phone:715-365-5256
Practice Address - Fax:715-365-5258
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28830208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI250006587OtherRAILROAD MEDICARE
WI31572600Medicaid
WI000044065Medicare PIN
WI250006587OtherRAILROAD MEDICARE