Healthcare Provider Details

I. General information

NPI: 1386628758
Provider Name (Legal Business Name): CLIFFORD J OPATKEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 W LINCOLN AVE
WEST ALLIS WI
53227-2409
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4257
US

V. Phone/Fax

Practice location:
  • Phone: 414-328-6000
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax: 262-782-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number27290-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2000146130
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: