Provider Demographics
NPI:1386628758
Name:OPATKEN, CLIFFORD J (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:J
Last Name:OPATKEN
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 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-4026
Mailing Address - Fax:262-782-6040
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-328-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27290-020207L00000X
MO2000146130207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202980215Medicaid
WI30662700Medicaid
MO202980215Medicaid
MO343015236Medicare PIN
WI30662700Medicaid
WI0001-68113Medicare ID - Type UnspecifiedPROVIDER NUMBER