Provider Demographics
NPI:1669402541
Name:GULLBERG, ROBERT M (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:GULLBERG
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 1:3811 SPRING STREET
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1667
Mailing Address - Country:US
Mailing Address - Phone:262-687-8310
Mailing Address - Fax:262-687-8318
Practice Address - Street 1:3811 SPRING STREET
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405
Practice Address - Country:US
Practice Address - Phone:262-687-8310
Practice Address - Fax:262-687-8318
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27459207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B53294Medicare UPIN