Healthcare Provider Details

I. General information

NPI: 1881691418
Provider Name (Legal Business Name): PROMISE DZAKPASU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 N PORT WASHINGTON RD STE 200
GLENDALE WI
53212-1076
US

IV. Provider business mailing address

9000 W WISCONSIN AVE # MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-247-9530
  • Fax: 414-247-1875
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36766
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: