Provider Demographics
NPI:1457431819
Name:ALDSTADT, ROXANNA
Entity Type:Individual
Prefix:
First Name:ROXANNA
Middle Name:
Last Name:ALDSTADT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 PLEASANT VALLEY RD
Mailing Address - Street 2:OBSTETRICS AND GYNECOLOGY
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9274
Mailing Address - Country:US
Mailing Address - Phone:262-836-7300
Mailing Address - Fax:
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:OBSTETRICS AND GYNECOLOGY
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-836-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39954207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019OtherINTERNAL ID-MOTOR VEHICLE ID
WI1457431819Medicaid
WIWI1897405Medicare PIN
2019OtherINTERNAL ID-MOTOR VEHICLE ID
WIK400270742Medicare PIN