Healthcare Provider Details

I. General information

NPI: 1962756270
Provider Name (Legal Business Name): ADVANCED FOOT & ANKLE OF WISCONSIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19035 W CAPITOL DR SUITE 101
BROOKFIELD WI
53045-2755
US

IV. Provider business mailing address

19035 W CAPITOL DR SUITE 101
BROOKFIELD WI
53045-2755
US

V. Phone/Fax

Practice location:
  • Phone: 262-763-9007
  • Fax: 262-758-6134
Mailing address:
  • Phone: 262-763-9007
  • Fax: 262-763-8184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number924-25
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateWI

VIII. Authorized Official

Name: DR. MICHAEL KOKAT
Title or Position: D.P.M.
Credential: DPM
Phone: 262-763-9007