Healthcare Provider Details

I. General information

NPI: 1730186511
Provider Name (Legal Business Name): THOMAS J MANKIEWICZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 MICHELLE WITMER MEMORIAL DRIVE
NEW BERLIN WI
53151-5292
US

IV. Provider business mailing address

3610 MICHELLE WITMER MEMORIAL DRIVE
NEW BERLIN WI
53151-5292
US

V. Phone/Fax

Practice location:
  • Phone: 262-785-1366
  • Fax: 262-785-1383
Mailing address:
  • Phone: 262-785-1366
  • Fax: 262-785-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22449
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: