1255361002 NPI number — DR. LAWRENCE J MANDT PH.D.

Table of content: MARINA KNIGHT M.S. (NPI 1346378064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255361002 NPI number — DR. LAWRENCE J MANDT PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANDT
Provider First Name:
LAWRENCE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255361002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
S88W25730 EDGEWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUKWONAGO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53149-9609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-706-3391
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2254 MONROE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53711-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-223-9767
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1610 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 1610-57 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39088600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1011078 . This is a "PHYSICIANS PLUS ID NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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