Provider Demographics
NPI:1467567602
Name:DAUFENBACH, DONNA R (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:R
Last Name:DAUFENBACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-2032
Mailing Address - Country:US
Mailing Address - Phone:262-752-2100
Mailing Address - Fax:262-752-2126
Practice Address - Street 1:5333 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-2032
Practice Address - Country:US
Practice Address - Phone:262-752-2100
Practice Address - Fax:262-752-2126
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33374207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32111300Medicaid
BD3433098OtherDEA NUMBER
BD3433098OtherDEA NUMBER
WI32111300Medicaid