Provider Demographics
NPI:1790084002
Name:BOZICH, IRENE ISABEL (MD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:ISABEL
Last Name:BOZICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:ISABEL
Other - Last Name:MEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3200 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9274
Mailing Address - Country:US
Mailing Address - Phone:262-836-7300
Mailing Address - Fax:
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-836-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59933-20207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790084002Medicaid