Provider Demographics
NPI:1336254713
Name:DEGERE, MICHAEL W (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:DEGERE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8335
Practice Address - Country:US
Practice Address - Phone:920-926-8616
Practice Address - Fax:920-926-8098
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI841-25213ES0103X
OH36003567213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480033786OtherRAILROAD MEDICARE
0282450001Medicare Oscar/Certification
480033786OtherRAILROAD MEDICARE
OH4313681Medicare PIN