Healthcare Provider Details

I. General information

NPI: 1649399080
Provider Name (Legal Business Name): NORTH SHORE DERMATOLOGY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10303 N PORT WASHINGTON RD SUITE 101
MEQUON WI
53092-5760
US

IV. Provider business mailing address

10303 N PORT WASHINGTON RD SUITE 101
MEQUON WI
53092-5760
US

V. Phone/Fax

Practice location:
  • Phone: 262-240-0440
  • Fax: 262-240-0441
Mailing address:
  • Phone: 262-240-0440
  • Fax: 262-240-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY BONFIGLIO
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 262-240-0440