Provider Demographics
NPI:1467757948
Name:RONQUILLO, KAREN (MS, MD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:
Last Name:RONQUILLO
Suffix:
Gender:F
Credentials:MS, MD
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:DIZON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:300 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53187-3001
Mailing Address - Country:US
Mailing Address - Phone:414-708-8852
Mailing Address - Fax:262-364-3099
Practice Address - Street 1:20611 WATERTOWN RD STE C
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1871
Practice Address - Country:US
Practice Address - Phone:262-333-3173
Practice Address - Fax:262-333-3173
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55146-202083C0008X, 2083X0100X
FLACN 378208D00000X
WI55146-020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLET905ZOtherMEDICARE PTAN
FL003237000Medicaid