Healthcare Provider Details

I. General information

NPI: 1659690717
Provider Name (Legal Business Name): MARCO SANUDO LOAYZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/13/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17345 CIVIC DR STE 1327
BROOKFIELD WI
53045-5070
US

IV. Provider business mailing address

PO BOX 1327
BROOKFIELD WI
53008-1327
US

V. Phone/Fax

Practice location:
  • Phone: 414-447-7330
  • Fax: 414-447-1070
Mailing address:
  • Phone: 414-447-7330
  • Fax: 414-447-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number73228
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25149
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number73228
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: