Healthcare Provider Details

I. General information

NPI: 1992968093
Provider Name (Legal Business Name): ELIZABETH J PLOVANICH DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 UNIVERSITY AVE SUITE 204
MIDDLETON WI
53562-3485
US

IV. Provider business mailing address

6255 UNIVERSITY AVE SUITE 204
MIDDLETON WI
53562-3485
US

V. Phone/Fax

Practice location:
  • Phone: 608-831-8086
  • Fax: 608-442-0126
Mailing address:
  • Phone: 608-831-8086
  • Fax: 608-442-0126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number967
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: