Provider Demographics
NPI:1265676829
Name:DEDMON, ROBERT E (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:E
Last Name:DEDMON
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 1:333 PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2875
Mailing Address - Country:US
Mailing Address - Phone:920-725-3939
Mailing Address - Fax:920-725-1011
Practice Address - Street 1:333 PARK DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2875
Practice Address - Country:US
Practice Address - Phone:920-725-3939
Practice Address - Fax:920-725-1011
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14725-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIF54418Medicare UPIN