Provider Demographics
NPI:1659815561
Name:MARKHAM, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:MARKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7949
Mailing Address - Country:US
Mailing Address - Phone:920-232-2332
Mailing Address - Fax:
Practice Address - Street 1:505 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7949
Practice Address - Country:US
Practice Address - Phone:920-232-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI226325-30163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740651330Medicaid