Provider Demographics
NPI:1184705543
Name:BREITENBACH, ROBERT A (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:BREITENBACH
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 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:123 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:MN
Practice Address - Zip Code:55974-1318
Practice Address - Country:US
Practice Address - Phone:507-498-3302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN335587000Medicaid
MN335587000Medicaid
MN080003752Medicare PIN