Healthcare Provider Details

I. General information

NPI: 1346532678
Provider Name (Legal Business Name): MICHAEL R MANKOVECKY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1779 MAIN ST
GREEN BAY WI
54302-3250
US

IV. Provider business mailing address

1779 MAIN ST
GREEN BAY WI
54302-3250
US

V. Phone/Fax

Practice location:
  • Phone: 920-465-0181
  • Fax:
Mailing address:
  • Phone: 920-465-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1036
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: