Provider Demographics
NPI:1164926499
Name:STEINER, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:STEINER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:414-423-5250
Mailing Address - Fax:414-423-5256
Practice Address - Street 1:4202 W OAKWOOD PARK CT
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9118
Practice Address - Country:US
Practice Address - Phone:414-423-5250
Practice Address - Fax:414-423-5256
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73679-20207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100102091Medicaid