Provider Demographics
NPI:1770536534
Name:PRYBA, DAVID E (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:E
Last Name:PRYBA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11211 W LINCOLN AVE
Mailing Address - Street 2:LINCOLN AVENUE CLINIC
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1035
Mailing Address - Country:US
Mailing Address - Phone:414-456-5950
Mailing Address - Fax:414-327-7639
Practice Address - Street 1:11211 W LINCOLN AVE
Practice Address - Street 2:LINCOLN AVENUE CLINIC
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1035
Practice Address - Country:US
Practice Address - Phone:414-456-5950
Practice Address - Fax:414-327-7639
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI35625207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000217QOtherHUMANA
WI1770536534Medicaid
G48750Medicare UPIN
WI1770536534Medicaid