Provider Demographics
NPI:1841487345
Name:CAMENGA, DAVID LEROY (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LEROY
Last Name:CAMENGA
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 1:420 E STARK RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-8300
Mailing Address - Country:US
Mailing Address - Phone:320-630-3203
Mailing Address - Fax:
Practice Address - Street 1:420 E STARK RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WI
Practice Address - Zip Code:53563-8300
Practice Address - Country:US
Practice Address - Phone:320-630-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN314402084N0400X
WI31720-0202084N0400X
FLME 935472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN287508000Medicaid
WI38724800Medicaid
WI32753000Medicaid
D48453Medicare UPIN
MN287508000Medicaid
MN08200Medicare PIN