Provider Demographics
NPI:1700837879
Name:DAMITZ, BETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:A
Last Name:DAMITZ
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2400 W VILLARD AVE
Mailing Address - Street 2:WFHC GLENDALE FAMILY CENTER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4901
Mailing Address - Country:US
Mailing Address - Phone:414-527-8191
Mailing Address - Fax:414-527-8046
Practice Address - Street 1:2400 W VILLARD AVE
Practice Address - Street 2:WFHC GLENDALE FAMILY CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4901
Practice Address - Country:US
Practice Address - Phone:414-527-8191
Practice Address - Fax:414-527-8046
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI39570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700837879Medicaid
000025937BOtherHUMANA
G75116Medicare UPIN
WI009F 73-601Medicare PIN