Provider Demographics
NPI:1093822587
Name:MIELKE, MICHELLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:MIELKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:915 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3994
Practice Address - Country:US
Practice Address - Phone:262-569-2300
Practice Address - Fax:262-569-2202
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI43366208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34085900Medicaid
WI34085900Medicaid
BM7299161OtherDEA NUMBER