Provider Demographics
NPI:1356316483
Name:VAN FOSSEN, KATHARINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:VAN FOSSEN
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 1:1411 N TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3043
Mailing Address - Country:US
Mailing Address - Phone:262-255-2500
Mailing Address - Fax:
Practice Address - Street 1:2555 N DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2709
Practice Address - Country:US
Practice Address - Phone:414-372-8080
Practice Address - Fax:414-562-8447
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42284207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33336700Medicaid
WIH16833Medicare UPIN
WI0235Medicare ID - Type Unspecified