Provider Demographics
NPI:1255334330
Name:RESEN, DAVID E (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:RESEN
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:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0043
Mailing Address - Country:US
Mailing Address - Phone:920-376-1255
Mailing Address - Fax:
Practice Address - Street 1:8619 EDGEWATER RDG
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-9760
Practice Address - Country:US
Practice Address - Phone:920-376-1256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32951207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33321900Medicaid
000026051Medicare PIN
WI33321900Medicaid