Provider Demographics
NPI:1427053032
Name:BROTANEK, JANE M (MD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:BROTANEK
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 1:38B GROVE STREET
Mailing Address - Street 2:RIDGEFIELD PEDIATRIC ASSOCIATES
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877
Mailing Address - Country:US
Mailing Address - Phone:203-438-9557
Mailing Address - Fax:203-438-7857
Practice Address - Street 1:38B GROVE STREET
Practice Address - Street 2:RIDGEFIELD PEDIATRIC ASSOCIATES
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877
Practice Address - Country:US
Practice Address - Phone:203-438-9557
Practice Address - Fax:203-438-7857
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47361208000000X
CT050206208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34580500Medicaid
WI02162343OtherMEDICAID/MCW
WI605885158003OtherBC/BS
WI7189387OtherAETNA
WI7189387OtherAETNA
WI02162343OtherMEDICAID/MCW
WI0073Medicare ID - Type Unspecified