Healthcare Provider Details

I. General information

NPI: 1164426763
Provider Name (Legal Business Name): ROBERT D MATTEUCCI D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8153 S 27TH ST SUITE 400
FRANKLIN WI
53132-9549
US

IV. Provider business mailing address

8153 S 27TH ST SUITE 400
FRANKLIN WI
53132-9549
US

V. Phone/Fax

Practice location:
  • Phone: 414-761-0981
  • Fax: 414-761-1614
Mailing address:
  • Phone: 414-761-0981
  • Fax: 414-761-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number881025
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005168
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: