Provider Demographics
NPI:1609946292
Name:EARLES, RENE MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:MARTIN
Last Name:EARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2221 S WEBSTER AVE
Mailing Address - Street 2:STE 241
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2158
Mailing Address - Country:US
Mailing Address - Phone:920-965-0345
Mailing Address - Fax:920-273-6011
Practice Address - Street 1:2221 S WEBSTER AVE
Practice Address - Street 2:STE 241
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2158
Practice Address - Country:US
Practice Address - Phone:920-965-0345
Practice Address - Fax:920-273-6011
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044864207N00000X
WI54674-20207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021606246OtherBCBS
C25220Medicare UPIN
IL471081Medicare ID - Type Unspecified