Provider Demographics
NPI:1780673053
Name:WEBER, ROBERT R (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:WEBER
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 1:2700 W 9TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7247
Mailing Address - Country:US
Mailing Address - Phone:920-223-3550
Mailing Address - Fax:
Practice Address - Street 1:2700 W 9TH AVE
Practice Address - Street 2:STE 310
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7247
Practice Address - Country:US
Practice Address - Phone:920-223-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30267208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31518900Medicaid
E13778Medicare UPIN
WI0513 71018Medicare PIN