Provider Demographics
NPI:1487630026
Name:DEVRIES, GLENN F (DPM)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:F
Last Name:DEVRIES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 E FOND DU LAC ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-9500
Mailing Address - Country:US
Mailing Address - Phone:920-748-3009
Mailing Address - Fax:920-748-3109
Practice Address - Street 1:680 E FOND DU LAC ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-9500
Practice Address - Country:US
Practice Address - Phone:920-748-3009
Practice Address - Fax:920-748-3109
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI467213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT61765Medicare UPIN
WI85640Medicare ID - Type Unspecified