Provider Demographics
NPI:1063494441
Name:DESUTTER, ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DESUTTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701C N RAILROAD ST
Mailing Address - Street 2:PO BOX 851
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-8833
Mailing Address - Country:US
Mailing Address - Phone:715-479-4214
Mailing Address - Fax:715-479-4214
Practice Address - Street 1:701C N RAILROAD ST
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-8833
Practice Address - Country:US
Practice Address - Phone:715-479-4214
Practice Address - Fax:715-479-4214
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1641111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI75475Medicare ID - Type Unspecified
WIT61762Medicare UPIN