Provider Demographics
NPI:1801829213
Name:DEGROOT, DANIEL L (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:DEGROOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:PREVEA HEALTH
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-436-1309
Practice Address - Street 1:900 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3508
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-436-1309
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31534208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32058600Medicaid
WI32058600Medicaid
F91964Medicare UPIN