Healthcare Provider Details

I. General information

NPI: 1194137026
Provider Name (Legal Business Name): MELISSA FAUBERT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 VALLEY DR
LODI WI
53555-1464
US

IV. Provider business mailing address

2817 NEW PINERY RD
PORTAGE WI
53901-9240
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-3296
  • Fax:
Mailing address:
  • Phone: 608-745-4598
  • Fax: 608-745-6393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.143132
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number69524-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: