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General NPI Number Information
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NPI Number | 1396032405
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Entity Type | Individual
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Provider Name | SAINT VICTOR ONE M.D
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Gender | Male
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Dates
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Enumeration Date | 07/09/2011
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Last Update Date | 02/24/2020
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Provider Practice Location Address
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Address Line | 9008 W BURLEIGH ST
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City | MILWAUKEE
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State | WI
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Zip | 53222-3632
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Country | US
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Telephone | 262-724-6867
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Fax |
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Provider Business Mailing Address
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Address Line | 1345 N JEFFERSON ST # 134
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City | MILWAUKEE
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State | WI
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Zip | 53202-2644
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Country | US
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Telephone | 262-724-6867
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 59931-20
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License Number State | WI
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