Provider Demographics
NPI:1619951498
Name:CAMILLI, KAREN M (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:CAMILLI
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 1:555 REDBIRD CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7977
Mailing Address - Country:US
Mailing Address - Phone:920-338-6820
Mailing Address - Fax:
Practice Address - Street 1:555 REDBIRD CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7977
Practice Address - Country:US
Practice Address - Phone:920-338-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18338208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI18338OtherLICENSE
WI000049Medicare Oscar/Certification
B51930Medicare UPIN
WI072900063Medicare Oscar/Certification
WI18338OtherLICENSE
WI000066Medicare Oscar/Certification