Provider Demographics
NPI:1497066732
Name:STAUFFER, MATTHEW ERIC (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ERIC
Last Name:STAUFFER
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 1:111 E WISCONSIN AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4815
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:
Practice Address - Street 1:9555 76TH ST
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1984
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097287207P00000X, 390200000X
WI61053-20207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1497066732Medicaid
WIP01319713OtherMEDICARE RAILROAD
WIP01269460OtherMEDICARE RAILROAD
WI1497066732Medicaid
WI323500097Medicare PIN
WI322800092Medicare PIN