Provider Demographics
NPI:1245210624
Name:ERDMAN, BARRY ELLIS (DPM)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:ELLIS
Last Name:ERDMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 S LAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915
Mailing Address - Country:US
Mailing Address - Phone:920-882-9990
Mailing Address - Fax:920-882-9544
Practice Address - Street 1:2005 S LAKE PARK RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4155
Practice Address - Country:US
Practice Address - Phone:920-882-9990
Practice Address - Fax:920-882-9544
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI616025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI010556903-011OtherANTHEM BLUE CROSS BLUE S
WI43206700Medicaid
WI010556903-011OtherANTHEM BLUE CROSS BLUE S
T93136Medicare UPIN
WI43206700Medicaid