Provider Demographics
NPI:1962477836
Name:NAKATA, MARIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:L
Last Name:NAKATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK STREET
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9146
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:17100 W NORTH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4436
Practice Address - Country:US
Practice Address - Phone:262-784-3800
Practice Address - Fax:262-784-7936
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31851020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30381500Medicaid
WIBN3047102OtherDEA
WI000368105Medicare ID - Type Unspecified
WI30381500Medicaid