Provider Demographics
NPI:1285800367
Name:KONETZKI, WAYNE HARRY (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:HARRY
Last Name:KONETZKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4913
Mailing Address - Country:US
Mailing Address - Phone:262-547-3055
Mailing Address - Fax:262-547-2129
Practice Address - Street 1:403 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4913
Practice Address - Country:US
Practice Address - Phone:262-547-3055
Practice Address - Fax:262-547-2129
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14469207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0001-68805OtherMEDICARE NUMBER
WIB54265Medicare UPIN