Provider Demographics
NPI:1457530446
Name:POWELL MATTIOLI, KATHLEEN MARY (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:POWELL MATTIOLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARY
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:8905 W LINCOLN AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2468
Practice Address - Country:US
Practice Address - Phone:414-978-2229
Practice Address - Fax:414-978-2279
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49339207V00000X
IL036-163299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35336200Medicaid
WI46236-0344Medicare PIN
WI019940345Medicare PIN