Provider Demographics
NPI:1437354602
Name:MIESFELD, JAY M (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:M
Last Name:MIESFELD
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 1:711 AVALON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-2304
Mailing Address - Country:US
Mailing Address - Phone:608-444-8025
Mailing Address - Fax:920-885-5506
Practice Address - Street 1:109 WARREN ST STE 4
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3082
Practice Address - Country:US
Practice Address - Phone:920-885-3305
Practice Address - Fax:920-885-5506
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8095208000000X
WI54813-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics