Provider Demographics
NPI:1063673903
Name:ELDRIDGE, MARY PATRICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:PATRICIA
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 75TH ST
Mailing Address - Street 2:SUITE #5
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1544
Mailing Address - Country:US
Mailing Address - Phone:262-656-1911
Mailing Address - Fax:888-316-8458
Practice Address - Street 1:1400 75TH ST
Practice Address - Street 2:SUITE #5
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1544
Practice Address - Country:US
Practice Address - Phone:262-656-1911
Practice Address - Fax:888-316-8458
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54685-20208D00000X
IAR-9497208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice