Provider Demographics
NPI:1649324641
Name:GARONZIK WANG, JACQUELINE MARY (MD PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARY
Last Name:GARONZIK WANG
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MARY
Other - Last Name:GARONZIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD PHD
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-1384
Practice Address - Fax:608-262-5624
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1441-320208600000X, 204F00000X
MDD0069174204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid