Healthcare Provider Details

I. General information

NPI: 1720283138
Provider Name (Legal Business Name): MARK P HASTINGS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 N 51ST BLVD
MILWAUKEE WI
53216-3228
US

IV. Provider business mailing address

3431 N 51ST BLVD
MILWAUKEE WI
53216-3228
US

V. Phone/Fax

Practice location:
  • Phone: 414-873-0772
  • Fax: 414-873-3933
Mailing address:
  • Phone: 414-873-7668
  • Fax: 414-873-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number659025
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: