Basic Information
| Provider Information | |||||||||
| NPI: | 1306833991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAPETSONIS | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 788 N JEFFERSON ST | ||||||||
| Address2: | SUITE 300/ATTN. KAAREN BUTZEN | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532023718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142746271 | ||||||||
| FaxNumber: | 4142720859 | ||||||||
| Practice Location | |||||||||
| Address1: | 734 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532024602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142776500 | ||||||||
| FaxNumber: | 4142241365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 01/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43438 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34283400 | 05 | WI | MEDICAID |