Provider Demographics
NPI:1184794034
Name:RIECAN, JAN (MD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:
Last Name:RIECAN
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 1:2500 NORTH MAYFAIR ROAD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1409
Mailing Address - Country:US
Mailing Address - Phone:414-774-1919
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH MAYFAIR ROAD
Practice Address - Street 2:SUITE 410
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1409
Practice Address - Country:US
Practice Address - Phone:414-774-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20319208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30211200Medicaid
B56053Medicare UPIN