Provider Demographics
NPI:1598714016
Name:ICENOGLE, DANIEL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEE
Last Name:ICENOGLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S7563 RILEY RD
Mailing Address - Street 2:
Mailing Address - City:READSTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54652-8030
Mailing Address - Country:US
Mailing Address - Phone:608-637-4260
Mailing Address - Fax:608-637-7492
Practice Address - Street 1:507 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-2059
Practice Address - Country:US
Practice Address - Phone:608-637-4260
Practice Address - Fax:608-637-7492
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3136880Medicaid
WI3136880Medicaid
WI01300202Medicare ID - Type Unspecified