Provider Demographics
NPI:1669529608
Name:BETTAG, STEVEN MARK (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:MARK
Last Name:BETTAG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 N TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1990
Mailing Address - Country:US
Mailing Address - Phone:920-458-7433
Mailing Address - Fax:920-452-3594
Practice Address - Street 1:1621 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1990
Practice Address - Country:US
Practice Address - Phone:920-458-7433
Practice Address - Fax:920-452-3594
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36813-020207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32158500Medicaid
F88849Medicare UPIN