Provider Demographics
NPI:1780751495
Name:MADENBERG, DAVID R (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:MADENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2950 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2655
Mailing Address - Country:US
Mailing Address - Phone:262-245-0535
Mailing Address - Fax:262-245-2248
Practice Address - Street 1:N2950 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2655
Practice Address - Country:US
Practice Address - Phone:262-245-0535
Practice Address - Fax:262-245-2248
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23659-21207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780751495Medicaid
WIMADENDAVOtherMERCYCARE INSURANCE
WI30019800Medicaid
IL$$$$$$$$$ 1Medicaid
WI541760876Medicare PIN
WI1780751495Medicaid
IL$$$$$$$$$ 1Medicaid