Healthcare Provider Details

I. General information

NPI: 1225034119
Provider Name (Legal Business Name): KARIE ANN MANTEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/21/2006

III. Provider practice location address

134 HOSPITAL DR
WATERTOWN WI
53098-3304
US

IV. Provider business mailing address

134 HOSPITAL DR
WATERTOWN WI
53098-3304
US

V. Phone/Fax

Practice location:
  • Phone: 920-261-6500
  • Fax: 920-261-6107
Mailing address:
  • Phone: 920-261-6500
  • Fax: 920-261-6107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45539
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: