Provider Demographics
NPI:1912929803
Name:GANZ, MARY L (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:GANZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 BETSY ROSS CT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1290 BETSY ROSS CT
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5362
Practice Address - Country:US
Practice Address - Phone:262-796-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI290092080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B52981Medicare UPIN