Healthcare Provider Details

I. General information

NPI: 1598110033
Provider Name (Legal Business Name): JENNIFER MAKRIDES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2873
  • Fax: 414-266-3905
Mailing address:
  • Phone: 414-266-2873
  • Fax: 414-266-3905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81029
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number81029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: