Healthcare Provider Details

I. General information

NPI: 1265407316
Provider Name (Legal Business Name): KENNETH URLAKIS JR. M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 VIOLET CT
COLGATE WI
53017-9319
US

IV. Provider business mailing address

631 VIOLET CT
COLGATE WI
53017-9319
US

V. Phone/Fax

Practice location:
  • Phone: 262-388-6217
  • Fax:
Mailing address:
  • Phone: 262-388-6217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37072
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37072-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: