Healthcare Provider Details

I. General information

NPI: 1407882087
Provider Name (Legal Business Name): JAN M MATOUSEK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E WISCONSIN AVE
MILWAUKEE WI
53202-4815
US

IV. Provider business mailing address

111 E WISCONSIN AVE
MILWAUKEE WI
53202-4815
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6720
  • Fax: 414-290-6755
Mailing address:
  • Phone: 414-290-6720
  • Fax: 414-290-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number32212-021
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number32212-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: