Basic Information
| Provider Information | |||||||||
| NPI: | 1285976209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DREIFKE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | BRENT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 S GREEN BAY RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626194191 | ||||||||
| FaxNumber: | 2626345185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2013 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 125063100 | IL | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 69757-20 | WI | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.