Provider Demographics
NPI:1275503922
Name:MARESCOT, KEASHA DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:KEASHA
Middle Name:DANIELLE
Last Name:MARESCOT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KEASHA
Other - Middle Name:DANIELLE
Other - Last Name:GRINDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1849
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1849
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-5363
Practice Address - Street 1:43 SOKOKIS TRAIL
Practice Address - Street 2:
Practice Address - City:E WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04030
Practice Address - Country:US
Practice Address - Phone:207-247-6742
Practice Address - Fax:207-247-6114
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
046260OtherANTHEM
NHM555815OtherCIGNA
3179929OtherAETNA
0055B749OtherCHAMPUS
NH30205519Medicaid
ME046261OtherBLUE SHIELD
050562391OtherCOMMERCIAL
ME281130099Medicaid
ME0000BMMedicare ID - Type Unspecified