Provider Demographics
NPI:1306100227
Name:DESARDEN, CONNIE ANJOLI (MD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:ANJOLI
Last Name:DESARDEN
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 1:3289 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3203
Mailing Address - Country:US
Mailing Address - Phone:414-771-7900
Mailing Address - Fax:414-607-6336
Practice Address - Street 1:3289 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3203
Practice Address - Country:US
Practice Address - Phone:414-771-7900
Practice Address - Fax:414-607-6336
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine