Provider Demographics
NPI:1184659724
Name:WAMPLER, ROBERT ELWOOD (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ELWOOD
Last Name:WAMPLER
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:PO BOX 19070
Mailing Address - Street 2:PREVEA HEALTH
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-431-1950
Practice Address - Street 1:3860 MONROE RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8399
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-431-1950
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21100207R00000X
WI21100-020207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30120500Medicaid
07125-0124Medicare ID - Type Unspecified
A01095Medicare UPIN