Provider Demographics
NPI:1871586818
Name:DESIDERO, STEPHEN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:DESIDERO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:14555 W NATIONAL AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4494
Practice Address - Country:US
Practice Address - Phone:262-827-3636
Practice Address - Fax:262-827-3626
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-11-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI36839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00627722OtherRR MEDICARE
WI32163400Medicaid
WI46236-0360Medicare PIN
WIG12710Medicare UPIN
WI32163400Medicaid