Provider Demographics
NPI:1255446506
Name:SODERBERG, MILTON D (MD)
Entity type:Individual
Prefix:DR
First Name:MILTON
Middle Name:D
Last Name:SODERBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1414 W FAIR AVE STE 240
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5409
Practice Address - Country:US
Practice Address - Phone:906-225-3939
Practice Address - Fax:906-225-7488
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301026190207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP54120001Medicare PIN
MIA77582Medicare UPIN
MI2025869Medicaid