Healthcare Provider Details

I. General information

NPI: 1043373830
Provider Name (Legal Business Name): JEFFREY WARD KALENAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MAYFAIR RD
MILWAUKEE WI
53226-1309
US

IV. Provider business mailing address

2600 N MAYFAIR RD
MILWAUKEE WI
53226-1309
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-4499
  • Fax: 414-266-4480
Mailing address:
  • Phone: 414-266-4499
  • Fax: 414-266-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberW127000
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number27000-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: