Provider Demographics
NPI:1386660454
Name:FENSTER, BRUCE PAUL (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:PAUL
Last Name:FENSTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:PREVEA HEALTH
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-496-4766
Practice Address - Street 1:1715 DOUSMAN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3211
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-496-4766
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI24153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30405700Medicaid
07125-0028Medicare ID - Type Unspecified
WI30405700Medicaid