Healthcare Provider Details

I. General information

NPI: 1265475719
Provider Name (Legal Business Name): THOMAS ROBERT MARCINIAK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7049 W PINEBERRY RDG
FRANKLIN WI
53132-8565
US

IV. Provider business mailing address

7049 W PINEBERRY RDG
FRANKLIN WI
53132-8565
US

V. Phone/Fax

Practice location:
  • Phone: 414-427-1999
  • Fax: 414-427-1999
Mailing address:
  • Phone: 414-427-1999
  • Fax: 414-427-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number461-25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: