Healthcare Provider Details

I. General information

NPI: 1619969391
Provider Name (Legal Business Name): JAMES ROBERT VAVRA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N GRANDVIEW BLVD STE 300
PEWAUKEE WI
53072-5591
US

IV. Provider business mailing address

2835 N GRANDVIEW BLVD STE 300
PEWAUKEE WI
53072-5591
US

V. Phone/Fax

Practice location:
  • Phone: 262-542-3779
  • Fax: 262-542-4428
Mailing address:
  • Phone: 262-542-3779
  • Fax: 262-542-4428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number696
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: