Provider Demographics
NPI:1558574475
Name:MISSETT, ANDREW MARK (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARK
Last Name:MISSETT
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 1:3645 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-1510
Mailing Address - Country:US
Mailing Address - Phone:414-332-9473
Mailing Address - Fax:
Practice Address - Street 1:3645 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-1510
Practice Address - Country:US
Practice Address - Phone:414-332-9473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25659-020208000000X
NY146690-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics