Provider Demographics
NPI:1093798324
Name:SYBESMA, WILLIAM G (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:SYBESMA
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 1:865 MULLEN DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6437
Mailing Address - Country:US
Mailing Address - Phone:920-744-4187
Mailing Address - Fax:
Practice Address - Street 1:865 MULLEN DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6437
Practice Address - Country:US
Practice Address - Phone:920-744-8147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21464207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI040008752OtherRAILROAD MEDICARE
WI39080723648OtherUNITY
WIWI0156OtherJOHN DEERE
WI30172100Medicaid
WI12573OtherDEAN
WI30172100Medicaid
WI040008752OtherRAILROAD MEDICARE