Provider Demographics
NPI:1588660195
Name:BENCIK BOUDREAU, KRISTIN D (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:D
Last Name:BENCIK BOUDREAU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:D
Other - Last Name:BENCIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:7950 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3131
Mailing Address - Country:US
Mailing Address - Phone:414-228-0099
Mailing Address - Fax:414-540-1065
Practice Address - Street 1:7950 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:FOX POINT
Practice Address - State:WI
Practice Address - Zip Code:53217-3131
Practice Address - Country:US
Practice Address - Phone:414-228-0099
Practice Address - Fax:414-540-0165
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32858800Medicaid
WIH39240Medicare UPIN
WI32858800Medicaid