Provider Demographics
NPI:1699753848
Name:MARSO, ANDREW J (DPM)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:MARSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 S 108TH STREET
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2525
Mailing Address - Country:US
Mailing Address - Phone:414-425-8400
Mailing Address - Fax:414-425-8425
Practice Address - Street 1:6130 S 108TH STREET
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2525
Practice Address - Country:US
Practice Address - Phone:414-425-8400
Practice Address - Fax:414-425-8425
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI896-025213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00717384OtherRAIL ROAD MEDICARE GROUP MEMBER PTAN #
WI43239300Medicaid
WIP00717384OtherRAIL ROAD MEDICARE GROUP MEMBER PTAN #
WIV05101Medicare UPIN
WI43239300Medicaid