Basic Information
| Provider Information | |||||||||
| NPI: | 1518963347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALDONADO | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153875511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 N OAK AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544495703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153875511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 09/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 59285 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 59285 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 59285 | NJ | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | 55941 | WI | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 55941 | WI | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 55941 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 1518963347 | 05 | WI | MEDICAID |