Provider Demographics
NPI:1659544211
Name:VAN ARENDONK, KYLE JON (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JON
Last Name:VAN ARENDONK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:J
Other - Last Name:VANARENDONK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6550
Mailing Address - Fax:414-266-6579
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6550
Practice Address - Fax:414-266-6579
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1491792086S0120X
WI69327-202086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH0007327OtherCGS - MEDICARE
OH0027771Medicaid
WI1659544211Medicaid