Provider Demographics
NPI:1942246509
Name:ILLICHMANN, MITCHELL L (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:L
Last Name:ILLICHMANN
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 1:7974 UW HEALTH COURT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-265-8130
Practice Address - Fax:608-263-7263
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI509882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry