Provider Demographics
NPI:1053367789
Name:DOYLE, MARYAM K (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:K
Last Name:DOYLE
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 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-6737
Mailing Address - Fax:262-782-6040
Practice Address - Street 1:10900 W POTTER RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3424
Practice Address - Country:US
Practice Address - Phone:414-774-9227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30056020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31773400Medicaid
WI31773400Medicaid
WI000104021Medicare PIN
WI000173925Medicare PIN
WI000146231Medicare PIN