Healthcare Provider Details

I. General information

NPI: 1306833991
Provider Name (Legal Business Name): MARIO KAPETSONIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 N JACKSON ST
MILWAUKEE WI
53202-4602
US

IV. Provider business mailing address

788 N JEFFERSON ST SUITE 300/ATTN. KAAREN BUTZEN
MILWAUKEE WI
53202-3718
US

V. Phone/Fax

Practice location:
  • Phone: 414-277-6500
  • Fax: 414-224-1365
Mailing address:
  • Phone: 414-274-6271
  • Fax: 414-272-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43438
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: