Healthcare Provider Details

I. General information

NPI: 1780812925
Provider Name (Legal Business Name): GWENDOLYN MARIA BETHENIS HOBEN M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N MAYFAIR RD
MILWAUKEE WI
53226
US

IV. Provider business mailing address

1155 N MAYFAIR RD
MILWAUKEE WI
53226-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-5990
  • Fax: 414-955-6282
Mailing address:
  • Phone: 414-955-5990
  • Fax: 414-955-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2009014205
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number66949
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: