Provider Demographics
NPI:1902815673
Name:VANDOMMELEN, DEBORAH BLETZINGER (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:BLETZINGER
Last Name:VANDOMMELEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEBORAH
Other - Middle Name:SUE
Other - Last Name:BLETZINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:720 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4703
Mailing Address - Country:US
Mailing Address - Phone:414-661-4405
Mailing Address - Fax:414-661-3915
Practice Address - Street 1:1575 N RIVER CENTER DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-283-8444
Practice Address - Fax:414-283-8450
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34258200Medicaid
WI34258200Medicaid
011600034Medicare ID - Type UnspecifiedMEDICARE PROVIDER
WI34258200Medicaid