Basic Information
| Provider Information | |||||||||
| NPI: | 1750358198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUFFRIN | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4025 N 92ND ST | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532221613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143585437 | ||||||||
| FaxNumber: | 4143585451 | ||||||||
| Practice Location | |||||||||
| Address1: | 4025 N 92ND ST | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143585437 | ||||||||
| FaxNumber: | 4143585451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 29045 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 29045020 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 31434200 | 05 | WI | MEDICAID |