Healthcare Provider Details

I. General information

NPI: 1841230463
Provider Name (Legal Business Name): JOHN DAVID BIVINS II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/05/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 W LOOMIS RD
GREENDALE WI
53129-2448
US

IV. Provider business mailing address

6220 W LOOMIS RD
GREENDALE WI
53129-2448
US

V. Phone/Fax

Practice location:
  • Phone: 414-423-0555
  • Fax:
Mailing address:
  • Phone: 414-423-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45682-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: