Provider Demographics
NPI:1245481142
Name:KETTERHAGEN, JAMES PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:PATRICK
Last Name:KETTERHAGEN
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 1:204 N 86TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4608
Mailing Address - Country:US
Mailing Address - Phone:561-319-2133
Mailing Address - Fax:561-634-2015
Practice Address - Street 1:204 N 86TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4608
Practice Address - Country:US
Practice Address - Phone:561-319-2133
Practice Address - Fax:561-634-2015
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 102903208600000X
WI22425208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery