Doctor Name: | MARK DEFORD |
NPI Number: | 1003158908 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | M.D. |
License Number: | |
Business Practice Address: | 9200 W Wisconsin Ave Department Of Pm&r Milwaukee, WI - 532263522 |
Business Phone Number: | 4148053666 |
Business Fax Number: | |
Mailing Address: | 9200 W Wisconsin Ave, Department Of Pm&r MILWAUKEE |
State: | WI |
Postal Code: | 532263522 |
Phone Number: | |
Fax Number: | |
NPI Enumeration Date: | 03/19/2013 |
NPI Last Update Date: | 02/10/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 390200000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Student, Health Care |
Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |