Provider Demographics
NPI:1841495058
Name:ANCLAM, JEREMY ROBERT (DO)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:ROBERT
Last Name:ANCLAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-2591
Mailing Address - Fax:920-320-5106
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-9662
Practice Address - Country:US
Practice Address - Phone:920-320-6212
Practice Address - Fax:920-684-5548
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101017285207R00000X
WI60788207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine