Provider Demographics
NPI:1104858836
Name:EENIGENBURG, ROYLE G JR (MD)
Entity Type:Individual
Prefix:
First Name:ROYLE
Middle Name:G
Last Name:EENIGENBURG
Suffix:JR
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 1:199 COUNTY ROAD DF
Mailing Address - Street 2:FL 3
Mailing Address - City:JUNEAU
Mailing Address - State:WI
Mailing Address - Zip Code:53039-9512
Mailing Address - Country:US
Mailing Address - Phone:920-386-4094
Mailing Address - Fax:920-386-3812
Practice Address - Street 1:199 COUNTY ROAD DF
Practice Address - Street 2:FL 3
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-9512
Practice Address - Country:US
Practice Address - Phone:920-386-4094
Practice Address - Fax:920-386-3812
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI345042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31968600Medicaid
WI002084264Medicare ID - Type Unspecified
WI31968600Medicaid