Provider Demographics
NPI:1346532678
Name:MANKOVECKY, MICHAEL R (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MANKOVECKY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1779 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3250
Mailing Address - Country:US
Mailing Address - Phone:920-465-0181
Mailing Address - Fax:
Practice Address - Street 1:1779 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3250
Practice Address - Country:US
Practice Address - Phone:920-465-0181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1036213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program