Provider Demographics
NPI:1053317594
Name:IHDE, DEBORAH A (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:IHDE
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 1:820 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3483
Mailing Address - Country:US
Mailing Address - Phone:920-731-5811
Mailing Address - Fax:920-738-6293
Practice Address - Street 1:2500 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-731-5811
Practice Address - Fax:920-738-6293
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32498800Medicaid