Provider Demographics
NPI:1811074370
Name:URUETA MAZZILLI, HEDY (MD)
Entity type:Individual
Prefix:
First Name:HEDY
Middle Name:
Last Name:URUETA MAZZILLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6012
Mailing Address - Country:US
Mailing Address - Phone:414-227-1127
Mailing Address - Fax:414-765-9767
Practice Address - Street 1:163 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6012
Practice Address - Country:US
Practice Address - Phone:414-227-1127
Practice Address - Fax:414-765-9767
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49060207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34735900Medicaid
WI49060-020OtherSTATE MEDICAL LICENSE