Provider Demographics
NPI:1598713026
Name:DEVERMANN, ROBERT B (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:DEVERMANN
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 1:1810 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2511
Mailing Address - Country:US
Mailing Address - Phone:920-236-9126
Mailing Address - Fax:
Practice Address - Street 1:620 WARREN ST
Practice Address - Street 2:
Practice Address - City:REDGRANITE
Practice Address - State:WI
Practice Address - Zip Code:54970-9391
Practice Address - Country:US
Practice Address - Phone:920-566-0620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32003100Medicaid
WIA01651Medicare UPIN