Healthcare Provider Details

I. General information

NPI: 1841264074
Provider Name (Legal Business Name): SIDNEY HERSZENSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N MAYFAIR RD SUITE 810
MILWAUKEE WI
53226-1309
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 414-771-1122
  • Fax: 414-771-1352
Mailing address:
  • Phone: 866-630-9882
  • Fax: 920-683-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number18537
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: