Healthcare Provider Details

I. General information

NPI: 1366700213
Provider Name (Legal Business Name): BRIAN W MENDENHALL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2012
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 FISH HATCHERY RD
MADISON WI
53715-1911
US

IV. Provider business mailing address

1808 W BELTLINE HWY
MADISON WI
53713-2334
US

V. Phone/Fax

Practice location:
  • Phone: 608-252-8000
  • Fax: 608-283-7193
Mailing address:
  • Phone: 608-280-4647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number61735
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: