Healthcare Provider Details

I. General information

NPI: 1427581685
Provider Name (Legal Business Name): CESAR AUGUSTO MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S 6TH ST 3RD FLOOR
MILWAUKEE WI
53204-2301
US

IV. Provider business mailing address

1028 S 9TH ST
MILWAUKEE WI
53204-1335
US

V. Phone/Fax

Practice location:
  • Phone: 414-643-8530
  • Fax: 414-647-8602
Mailing address:
  • Phone: 414-643-8530
  • Fax: 414-647-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2165-120
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: