Healthcare Provider Details

I. General information

NPI: 1730567074
Provider Name (Legal Business Name): MELISSA AZUL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
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: 414-266-2420
  • Fax: 414-266-6837
Mailing address:
  • Phone: 414-266-2420
  • Fax: 414-266-6837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number77105
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: