Healthcare Provider Details

I. General information

NPI: 1518209022
Provider Name (Legal Business Name): JUSTIN PETERSON DUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST STE 209
WAUKESHA WI
53188-3403
US

IV. Provider business mailing address

1111 DELAFIELD ST STE 209
WAUKESHA WI
53188-3403
US

V. Phone/Fax

Practice location:
  • Phone: 262-542-0444
  • Fax: 262-542-8214
Mailing address:
  • Phone: 262-542-0444
  • Fax: 262-542-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number62685-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: