Provider Demographics
NPI:1396761276
Name:PERZACKI, ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PERZACKI
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 1:1820 APPLETON RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1110
Mailing Address - Country:US
Mailing Address - Phone:920-996-2200
Mailing Address - Fax:920-996-2214
Practice Address - Street 1:1820 APPLETON RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1110
Practice Address - Country:US
Practice Address - Phone:920-996-2200
Practice Address - Fax:920-996-2214
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN473602084P0804X
WI42925-0202084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1043361OtherP1
MN405L5PEOtherBCBS
WI1396761276Medicaid
MN378616100Medicaid
MN48630OtherHP
MN104348OtherUC
MN15-55187OtherUBH
MN15-55187OtherUBH
MN48630OtherHP