Provider Demographics
NPI:1629023221
Name:HAVLIK, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:HAVLIK
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 1:1155 N MAYFAIR RD
Mailing Address - Street 2:PLASTIC SURGERY CENTER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-955-1000
Mailing Address - Fax:414-955-0183
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:PLASTIC SURGERY CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-1000
Practice Address - Fax:414-955-0183
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041790A2086S0122X
WI608592086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100347870Medicaid
WI1629023221Medicaid
WIK400098997Medicare PIN
WIK400098996Medicare PIN
E72246Medicare UPIN