Provider Demographics
NPI:1669456463
Name:FUGLESTAD, LOREN C (MD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:C
Last Name:FUGLESTAD
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 1:2714 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6715
Mailing Address - Country:US
Mailing Address - Phone:920-430-4760
Mailing Address - Fax:
Practice Address - Street 1:2714 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6715
Practice Address - Country:US
Practice Address - Phone:920-430-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35673207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01404701OtherRAIL ROAD MEDICARE
WI35673OtherLICENSE
WI000007Medicare Oscar/Certification
WI000012Medicare Oscar/Certification
WI000107305Medicare Oscar/Certification
WI000002Medicare Oscar/Certification
WI073050001Medicare Oscar/Certification
WI075100103Medicare Oscar/Certification
WI35673OtherLICENSE
WIP01404701OtherRAIL ROAD MEDICARE
WI430800031Medicare Oscar/Certification