Healthcare Provider Details

I. General information

NPI: 1780647263
Provider Name (Legal Business Name): MELANIE ANN MAILLOUX MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5433 W FOND DU LAC AVE
MILWAUKEE WI
53216-1382
US

IV. Provider business mailing address

9000 W WISCONSIN AVE MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-277-8900
  • Fax: 414-277-8939
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101231620
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number53698-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: