Healthcare Provider Details

I. General information

NPI: 1124512199
Provider Name (Legal Business Name): MARISSA ANN OBERSTADT DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA ANN HOELL

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S EXECUTIVE DR STE 101
BROOKFIELD WI
53005-4216
US

IV. Provider business mailing address

209 OAK KNOLL CT
HORTONVILLE WI
54944-9386
US

V. Phone/Fax

Practice location:
  • Phone: 888-964-6681
  • Fax: 888-662-0859
Mailing address:
  • Phone: 920-851-4057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1186-25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: