Basic Information
| Provider Information | |||||||||
| NPI: | 1609823806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAUWASSER | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3070 N 51ST ST | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532101645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144634259 | ||||||||
| FaxNumber: | 4144632728 | ||||||||
| Practice Location | |||||||||
| Address1: | 3070 N 51ST ST | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532101645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144634259 | ||||||||
| FaxNumber: | 4144632728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 09/07/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 18393-020 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 30172000 | 05 | WI | MEDICAID |