Provider Demographics
NPI:1811185283
Name:DEACON, MEXTON M (DPM)
Entity Type:Individual
Prefix:DR
First Name:MEXTON
Middle Name:M
Last Name:DEACON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 W FOND DU LAC AVE
Mailing Address - Street 2:STE 111
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1228
Mailing Address - Country:US
Mailing Address - Phone:414-326-9034
Mailing Address - Fax:414-763-2305
Practice Address - Street 1:1626 W FOND DU LAC AVE
Practice Address - Street 2:STE 111
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-1228
Practice Address - Country:US
Practice Address - Phone:414-326-9034
Practice Address - Fax:414-763-2305
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI949-25213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100000751Medicaid