Provider Demographics
NPI:1366463267
Name:PUFFER, DOUGLAS E (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:E
Last Name:PUFFER
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 1:4425 N PORT WASHINGTON ROAD
Mailing Address - Street 2:CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-326-2378
Mailing Address - Fax:414-326-2155
Practice Address - Street 1:13111 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2416
Practice Address - Country:US
Practice Address - Phone:262-243-7454
Practice Address - Fax:262-243-7482
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40365-020207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPUFFEDOUOtherMERCYCARE INSURANCE
WI34425400Medicaid
WIPUFFEDOUOtherMERCYCARE INSURANCE
H94107Medicare UPIN