Mark R Vytlacil, M.D.

Primary specialty

Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X

License

45815 Issued in WI

Practice address

6308 8TH Ave
Kenosha, WI 53143-5031

Phone

(262) 656-2943

Fax

(262) 656-2749

NPI assigned

Dec 19, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Froedtert South, Inc.

  • Family Medicine Physician
  • Kenosha, WI
  • NPI 1558305284
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1166486400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1033272174",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 130",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531410130",
            "telephone_number": "262-656-2943",
            "fax_number": "262-656-2749"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6308 8TH AVE",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531435031",
            "telephone_number": "262-656-2943",
            "fax_number": "262-656-2749"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VYTLACIL",
        "first_name": "MARK",
        "middle_name": "R",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-12-19",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "WI",
            "license": "45815",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "34409200",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kristen Volkman, MD
• Vop 52ND Ave Kenosha LLC
• Vop 52ND Ave Kenosha LLC
• Vop Kenosha, LLC
• Garrett Vucenic, LAT
• W E Opticians of Kenosha LTD
• Erin Wachter, LCSW
• Mary Wagner, COTA
• Monica Wagner, APSW
• Shelby Wagner, M.S., CCC-SLP

• Anatomic Pathology & Clinical Pathology Physician in Kenosha, WI
• Providers in Kenosha, WI by specialty
• Anatomic Pathology & Clinical Pathology Physician in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.