Provider Demographics
NPI:1407823156
Name:DEGROAT, JESSE VARNEY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:VARNEY
Last Name:DEGROAT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:709 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1137
Mailing Address - Country:US
Mailing Address - Phone:262-552-9137
Mailing Address - Fax:262-687-5657
Practice Address - Street 1:1320 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1978
Practice Address - Country:US
Practice Address - Phone:262-687-5630
Practice Address - Fax:262-687-5657
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44111-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3224200Medicaid
WI3224200Medicaid