Healthcare Provider Details

I. General information

NPI: 1568882793
Provider Name (Legal Business Name): KASSANDRA E HOLZEM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5320
  • Fax: 414-805-5323
Mailing address:
  • Phone: 414-805-5320
  • Fax: 414-805-5323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number6906320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: