Basic Information
| Provider Information | |||||||||
| NPI: | 1114999638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUDNOW | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2885 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532224404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
| FaxNumber: | 4142382424 | ||||||||
| Practice Location | |||||||||
| Address1: | 2885 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532224404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
| FaxNumber: | 4142382424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 42813 | WI | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | 42813-02 | WI | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 34199100 | 05 | WI | MEDICAID |