Provider Demographics
NPI:1457311441
Name:STODDARD, EMILY E (MD)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:E
Last Name:STODDARD
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 1:888 THACKERAY TRL STE 103
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4342
Mailing Address - Country:US
Mailing Address - Phone:262-567-1499
Mailing Address - Fax:262-567-4502
Practice Address - Street 1:888 THACKERAY TRL STE 103
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4342
Practice Address - Country:US
Practice Address - Phone:262-567-1499
Practice Address - Fax:262-567-4502
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI391612086S0129X, 208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34417500Medicaid
WI34417500Medicaid
WI000068840Medicare PIN
H91492Medicare UPIN