Healthcare Provider Details

I. General information

NPI: 1538248455
Provider Name (Legal Business Name): VERONA MAIERHOFER ITTIARA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE AVE
WILD ROSE WI
54984-6901
US

IV. Provider business mailing address

701 GROVE AVE
WILD ROSE WI
54984-6901
US

V. Phone/Fax

Practice location:
  • Phone: 920-622-3257
  • Fax:
Mailing address:
  • Phone: 920-622-5560
  • Fax: 920-622-5598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2012033510
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1905-850
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: