Provider Demographics
NPI:1225206899
Name:VICTORIA J. MONDLOCH MD SC
Entity type:Organization
Organization Name:VICTORIA J. MONDLOCH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MONDLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-524-9116
Mailing Address - Street 1:20800 SWENSON DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2058
Mailing Address - Country:US
Mailing Address - Phone:262-524-9116
Mailing Address - Fax:262-754-4943
Practice Address - Street 1:20800 SWENSON DR
Practice Address - Street 2:STE 425
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2058
Practice Address - Country:US
Practice Address - Phone:262-524-9116
Practice Address - Fax:262-754-4943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26004174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B55194Medicare UPIN
WI000046021Medicare PIN