Provider Demographics
NPI:1295785483
Name:KASTENBERG, IRA S (MD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:S
Last Name:KASTENBERG
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 97
Mailing Address - Street 2:
Mailing Address - City:POYNETTE
Mailing Address - State:WI
Mailing Address - Zip Code:53955-0097
Mailing Address - Country:US
Mailing Address - Phone:608-635-4343
Mailing Address - Fax:608-635-7094
Practice Address - Street 1:237 W SEWARD ST
Practice Address - Street 2:
Practice Address - City:POYNETTE
Practice Address - State:WI
Practice Address - Zip Code:53955-9584
Practice Address - Country:US
Practice Address - Phone:608-635-4343
Practice Address - Fax:608-635-7094
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20342-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI202OtherDEAN HEALTH INSURANCE
WI1000578OtherPHYSICIANS PLUS
WI30295300Medicaid
WI202OtherDEAN HEALTH INSURANCE
WI1000578OtherPHYSICIANS PLUS
WI080179102Medicare PIN
WI000613215Medicare PIN