Healthcare Provider Details

I. General information

NPI: 1083830335
Provider Name (Legal Business Name): GREGORY KAFTAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 30TH AVE
KENOSHA WI
53144-2871
US

IV. Provider business mailing address

2861 N PROSPECT AVE
MILWAUKEE WI
53211-3771
US

V. Phone/Fax

Practice location:
  • Phone: 262-658-7102
  • Fax:
Mailing address:
  • Phone: 414-961-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number34419
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: