Provider Demographics
NPI:1851019871
Name:MANDZIUK, JAKE (MD)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:MANDZIUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
Mailing Address - Street 2:9000 W. WISCONSIN AVE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-266-2255
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
Practice Address - Street 2:9000 W. WISCONSIN AVE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-266-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9953207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology