Provider Demographics
NPI:1134338841
Name:DIDION, MICHAEL ANTHONY (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:DIDION
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5916 NORTH GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3810
Mailing Address - Country:US
Mailing Address - Phone:262-242-6105
Mailing Address - Fax:262-242-5133
Practice Address - Street 1:3305 S 20TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4941
Practice Address - Country:US
Practice Address - Phone:414-384-2100
Practice Address - Fax:414-384-2700
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19384207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30032800Medicaid
B84803Medicare UPIN
80092Medicare ID - Type Unspecified