Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RE0101X | Endocrinologist (Diabetes Doctor) | 31137 | WI |
NPI | 1093823130 |
---|---|
Provider Name | Thomas Kelly |
First Address | Wauwatosa, WI 53226 |
Second Address | Wauwatosa, WI 53226 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2006 |
Last Update Date | 22/09/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
31597200 | (05) | WI |
D07380 | (02) | WI |