Provider Demographics
NPI:1639208440
Name:PHEISTER, MARA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARA
Middle Name:
Last Name:PHEISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 N 51ST ST STE 206
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1661
Mailing Address - Country:US
Mailing Address - Phone:414-585-7020
Mailing Address - Fax:414-585-7021
Practice Address - Street 1:3070 N 51ST ST STE 206
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1661
Practice Address - Country:US
Practice Address - Phone:414-585-7020
Practice Address - Fax:414-585-7021
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI526932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639208440Medicaid
WI68086 0458Medicare PIN
WI1639208440Medicaid