Provider Demographics
NPI:1063455079
Name:RETZER, DANIEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:RETZER
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:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:779-696-7342
Practice Address - Street 1:5665 N. JUNCTION WAY
Practice Address - Street 2:
Practice Address - City:DAVIS JUNCTION
Practice Address - State:IL
Practice Address - Zip Code:61020
Practice Address - Country:US
Practice Address - Phone:779-696-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036069878Medicaid
ILL71909Medicare UPIN
IL036069878Medicaid