Provider Demographics
NPI:1720196561
Name:BERTRAM, DOUGLAS EDWARD (LAC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:BERTRAM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 WINNEBAGO ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5559
Mailing Address - Country:US
Mailing Address - Phone:608-692-7785
Mailing Address - Fax:
Practice Address - Street 1:1628 WINNEBAGO ST APT 1
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5559
Practice Address - Country:US
Practice Address - Phone:608-692-7785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI482-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist