Provider Demographics
NPI:1922091628
Name:BENDER, WILLIAM LOGAN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LOGAN
Last Name:BENDER
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:S6296 PETERSON HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665
Mailing Address - Country:US
Mailing Address - Phone:608-675-3652
Mailing Address - Fax:
Practice Address - Street 1:S6296 PETERSON HILL ROAD
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665
Practice Address - Country:US
Practice Address - Phone:608-675-3652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19570207P00000X
ND3099207Q00000X
WI17175207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIA01551Medicare UPIN