Provider Demographics
NPI:1659453488
Name:MOSSBERG, JULIE E
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:E
Last Name:MOSSBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LONE OAK LN
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-2600
Mailing Address - Country:US
Mailing Address - Phone:262-670-1800
Mailing Address - Fax:
Practice Address - Street 1:110 LONE OAK LN
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2600
Practice Address - Country:US
Practice Address - Phone:262-670-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42549208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
3101OtherINTERNAL ID-MOTOR VEHICLE ID
H57392Medicare UPIN