Healthcare Provider Details

I. General information

NPI: 1417064999
Provider Name (Legal Business Name): MARK W MEWISSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 03/07/2023
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY #540
MILWAUKEE WI
53215
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-385-2429
  • Fax: 414-385-2461
Mailing address:
  • Phone: 414-647-6326
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28722
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: