Provider Demographics
NPI:1346664059
Name:DEFATTA ENT & FACIAL PLASTIC SURGERY SC
Entity Type:Organization
Organization Name:DEFATTA ENT & FACIAL PLASTIC SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DEFATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PH D, FACS
Authorized Official - Phone:715-828-2368
Mailing Address - Street 1:1490 RIVERS EDGE TRAIL
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-1495
Mailing Address - Country:US
Mailing Address - Phone:715-828-2368
Mailing Address - Fax:715-726-2087
Practice Address - Street 1:1490 RIVERS EDGE TRAIL
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-1495
Practice Address - Country:US
Practice Address - Phone:715-828-2368
Practice Address - Fax:715-726-2087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-17
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55984-20174400000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1578697520OtherNPI
WI100016459Medicaid
WI1790931707OtherNPI PROVIDER