Provider Demographics
NPI:1104890722
Name:MCCOMIS, MARY (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCCOMIS
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 1:721 AMERICAN AVE, STE 304
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-549-2229
Mailing Address - Fax:262-549-1657
Practice Address - Street 1:721 AMERICAN AVE, STE 304
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-549-2229
Practice Address - Fax:262-549-1657
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34707207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31961200Medicaid
WIF63318Medicare UPIN
WI31961200Medicaid