Healthcare Provider Details

I. General information

NPI: 1679524243
Provider Name (Legal Business Name): CLARISSE P ETHRIDGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 S STOUGHTON RD
MADISON WI
53716-2257
US

IV. Provider business mailing address

1821 S STOUGHTON RD
MADISON WI
53716-2257
US

V. Phone/Fax

Practice location:
  • Phone: 608-260-6000
  • Fax: 608-260-6595
Mailing address:
  • Phone: 608-260-6000
  • Fax: 608-260-6595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number36964-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: