Healthcare Provider Details

I. General information

NPI: 1073975322
Provider Name (Legal Business Name): MEISHA RAVEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

2239 ETON RDG
MADISON WI
53726-5303
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-3323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number6102851
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number68313-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: