Provider Demographics
NPI:1023004223
Name:PERRY, REBECCA D (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:PERRY
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 1:400 W GLEN ST
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-1355
Mailing Address - Country:US
Mailing Address - Phone:715-478-3318
Mailing Address - Fax:715-478-3255
Practice Address - Street 1:400 W GLEN ST
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-1355
Practice Address - Country:US
Practice Address - Phone:715-478-3318
Practice Address - Fax:715-478-3255
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22328207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B55370Medicare UPIN