Healthcare Provider Details

I. General information

NPI: 1104052521
Provider Name (Legal Business Name): EZRA TEITELBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE DEPT OF
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE DEPT OF
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-7113
  • Fax: 414-805-8097
Mailing address:
  • Phone: 414-955-7113
  • Fax: 414-805-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number85642
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number148293
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: