Provider Demographics
NPI:1306833991
Name:KAPETSONIS, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:KAPETSONIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300/ATTN. KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-274-6271
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:734 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4602
Practice Address - Country:US
Practice Address - Phone:414-277-6500
Practice Address - Fax:414-224-1365
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34283400Medicaid
WI34283400Medicaid