Healthcare Provider Details

I. General information

NPI: 1881636819
Provider Name (Legal Business Name): MICHAEL D PLOTKIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9233 N GREEN BAY RD
BROWN DEER WI
53209-1103
US

IV. Provider business mailing address

4425 N PORT WASHINGTON RD ATTN: CLINIC CREDENTIALING
GLENDALE WI
53212-1082
US

V. Phone/Fax

Practice location:
  • Phone: 414-270-8150
  • Fax:
Mailing address:
  • Phone: 414-270-8150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39967
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: