Provider Demographics
NPI:1346212545
Name:POWELL, IAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:R
Last Name:POWELL
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 1:34700 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34700 VALLEY RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4500
Practice Address - Country:US
Practice Address - Phone:262-646-1391
Practice Address - Fax:262-646-1393
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39133103TA0400X, 207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32580600Medicaid
H05048Medicare UPIN
WI32580600Medicaid