Provider Demographics
NPI:1225047525
Name:GOTWALT, KAREN (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:GOTWALT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N MAYFAIR RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4216
Mailing Address - Country:US
Mailing Address - Phone:414-771-8228
Mailing Address - Fax:414-256-2483
Practice Address - Street 1:201 N MAYFAIR RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-771-8228
Practice Address - Fax:414-256-2483
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28663207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31786900Medicaid
WIBG1154400OtherDEA LICENSE
73840Medicare ID - Type Unspecified
WI31786900Medicaid