Provider Demographics
NPI:1932163110
Name:ECCLES ROTAR, DEANNE K (MD)
Entity Type:Individual
Prefix:
First Name:DEANNE
Middle Name:K
Last Name:ECCLES ROTAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEANNE
Other - Middle Name:K
Other - Last Name:ECCLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3200 E RACINE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2343
Mailing Address - Country:US
Mailing Address - Phone:608-371-8000
Mailing Address - Fax:608-371-8932
Practice Address - Street 1:3200 E RACINE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2343
Practice Address - Country:US
Practice Address - Phone:608-371-8000
Practice Address - Fax:608-371-8932
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40546-020207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932163110Medicaid
WI6690OtherDEAN HEALTH INSURANCE
WI6690OtherDEAN HEALTH INSURANCE
WI32493400Medicaid
G24810Medicare UPIN
WI080130767Medicare PIN