Provider Demographics
NPI:1801868047
Name:BERTRAM, KARL J (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:J
Last Name:BERTRAM
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:835 PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-8505
Practice Address - Country:US
Practice Address - Phone:920-745-3540
Practice Address - Fax:920-745-7932
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41089208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32557700Medicaid
WI32557700Medicaid
WIK400137156Medicare PIN
WIK400137155Medicare PIN