Healthcare Provider Details

I. General information

NPI: 1437310596
Provider Name (Legal Business Name): MARY ELIZABETH BURNETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELIZABETH CASTILLO M.D.

II. Dates (important events)

Enumeration Date: 06/21/2008
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N MAYFAIR RD SUITE 220
WAUWATOSA WI
53226-1415
US

IV. Provider business mailing address

2500 N MAYFAIR RD SUITE 220
WAUWATOSA WI
53226-1409
US

V. Phone/Fax

Practice location:
  • Phone: 414-475-9101
  • Fax: 414-475-9203
Mailing address:
  • Phone: 414-475-9101
  • Fax: 414-475-9203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number63139
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301092230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: