Provider Demographics
NPI:1770534208
Name:AUGUSTSON, MICHAEL K (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:AUGUSTSON
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 1:705 S UNIVERSITY AVE
Mailing Address - Street 2:STE 510
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3081
Mailing Address - Country:US
Mailing Address - Phone:920-885-8586
Mailing Address - Fax:920-885-8771
Practice Address - Street 1:705 S UNIVERSITY AVE
Practice Address - Street 2:STE 510
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3081
Practice Address - Country:US
Practice Address - Phone:920-885-8586
Practice Address - Fax:920-885-8771
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27426-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770534208Medicaid
WI1770534208Medicaid
WIK400176173Medicare PIN
WI30715200Medicaid
WIK400126192Medicare PIN
WIK400126192Medicare PIN