Provider Demographics
NPI:1386626562
Name:WEBER, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:WEBER
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 1:2000 N DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1049
Mailing Address - Country:US
Mailing Address - Phone:608-768-3900
Mailing Address - Fax:608-524-1947
Practice Address - Street 1:2000 N DEWEY AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1049
Practice Address - Country:US
Practice Address - Phone:608-768-3900
Practice Address - Fax:608-524-1947
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28989207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI16008OtherDEAN HEALTH INSURANCE
WI31575100Medicaid
W010562OtherCHAMPUS
WI0676320001OtherMEDICARE DME
WI1386626562OtherPHYSICIANS PLUS
WI000257010OtherMEDICARE PROVIDER ID NUMBER
WI504547638OtherTRICARE
WI000257010OtherMEDICARE PROVIDER ID NUMBER
WI1386626562OtherPHYSICIANS PLUS