Provider Demographics
NPI:1194899005
Name:MOMPER, STEPHANIE ANNE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:MOMPER
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 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:262-250-7800
Mailing Address - Fax:
Practice Address - Street 1:N112W15415 MEQUON RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-3410
Practice Address - Country:US
Practice Address - Phone:262-250-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50349207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics