Provider Demographics
NPI:1730186511
Name:MANKIEWICZ, THOMAS J (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:MANKIEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3610 MICHELLE WITMER MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5292
Mailing Address - Country:US
Mailing Address - Phone:262-785-1366
Mailing Address - Fax:262-785-1383
Practice Address - Street 1:3610 MICHELLE WITMER MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5292
Practice Address - Country:US
Practice Address - Phone:262-785-1366
Practice Address - Fax:262-785-1383
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22449207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30373500Medicaid
WI680020002Medicare ID - Type Unspecified
WI30373500Medicaid