Provider Demographics
NPI:1003947649
Name:BARSOTTI, BENJAMIN BRUNO (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRUNO
Last Name:BARSOTTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 WESTHILL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3769
Mailing Address - Country:US
Mailing Address - Phone:509-731-7199
Mailing Address - Fax:
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-706-6892
Practice Address - Fax:541-706-6813
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73175-20208000000X, 2083C0008X
PAMT 189428208000000X
DEC7000-3519208000000X
WAMD60085554208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8543779Medicaid
WA0251413OtherLABOR AND INDUSTRIES
WAG8883198Medicare PIN
WAAB38059Medicare Oscar/Certification