Provider Demographics
NPI:1255910683
Name:JOSEPHSON, ALYSSA LYNN (MD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LYNN
Last Name:JOSEPHSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:LYNN
Other - Last Name:TIDEMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8701 W WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4855 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-432-7599
Practice Address - Fax:262-432-7694
Is Sole Proprietor?:No
Enumeration Date:2021-04-04
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI7772220208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255910683Medicaid