Provider Demographics
NPI:1235572447
Name:DEWATERS, MARY ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:DEWATERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W CAPITOL DR.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3732
Mailing Address - Country:US
Mailing Address - Phone:414-906-5306
Mailing Address - Fax:144-906-4533
Practice Address - Street 1:210 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3732
Practice Address - Country:US
Practice Address - Phone:144-906-5306
Practice Address - Fax:144-906-4533
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235572447Medicaid