Provider Demographics
NPI:1710085048
Name:EJERCITO, MICHAEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:EJERCITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 628156
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-8156
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-623-1227
Practice Address - Street 1:202 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1507
Practice Address - Country:US
Practice Address - Phone:608-417-6206
Practice Address - Fax:608-417-6051
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI047785207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34682000Medicaid
I16367Medicare UPIN
WI743300057Medicare PIN