Provider Demographics
NPI:1154446839
Name:WETZLER, ROBERT J
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WETZLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W341N6766 LANCELOT DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 E CAPITOL DR
Practice Address - Street 2:SUITE A
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1208
Practice Address - Country:US
Practice Address - Phone:414-372-5553
Practice Address - Fax:414-372-7003
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31176000Medicaid
WIB85348Medicare UPIN