Healthcare Provider Details

I. General information

NPI: 1396233177
Provider Name (Legal Business Name): MITALI SUKUMAR THANAWALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE CHW MS B620
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE CHW MS B620
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-6730
  • Fax: 414-266-6742
Mailing address:
  • Phone: 414-266-6730
  • Fax: 414-266-6742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number86337-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: