Provider Demographics
NPI:1083774830
Name:WEFFENSTETTE, BRUCE E (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:WEFFENSTETTE
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 1:1300 SOUTH DR.
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-236-2931
Practice Address - Street 1:1300 SOUTH DR.
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-236-2931
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI218882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30425200Medicaid
WIAWOtherDEA
WIE86645Medicare UPIN
WI30425200Medicaid