Provider Demographics
NPI:1568459998
Name:MANTEI, ELWYN C (MD)
Entity Type:Individual
Prefix:
First Name:ELWYN
Middle Name:C
Last Name:MANTEI
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 1:3123 SHORE DR
Mailing Address - Street 2:STE 102
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4287
Mailing Address - Country:US
Mailing Address - Phone:715-732-2299
Mailing Address - Fax:715-732-2419
Practice Address - Street 1:3123 SHORE DR
Practice Address - Street 2:STE 102
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4287
Practice Address - Country:US
Practice Address - Phone:715-732-2299
Practice Address - Fax:715-732-2419
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22450020207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI110221390OtherRR-MEDICARE
MIN41200005Medicaid
WI30265400Medicaid
B54815Medicare UPIN
WI000240160Medicare Oscar/Certification
WI003540165Medicare Oscar/Certification
WI110221390OtherRR-MEDICARE
MIN41200005Medicaid