Healthcare Provider Details

I. General information

NPI: 1891779005
Provider Name (Legal Business Name): PRIMITIVO I REYNALDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 W INNOVATION DR SUITE 700
MILWAUKEE WI
53226-4825
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4266
US

V. Phone/Fax

Practice location:
  • Phone: 414-302-9196
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20320-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: