MEDICARE: DR. WILLIAM J DIERBERG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	31110-020	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	31110-020	OTHER	WI	MEDICAL LICENSE

General Provider Information

NPI Number	:	1013910785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM J DIERBERG M.D.

Provider Business Mailing Address
First Line	:	2073 WINTERGREEN CT
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-1946
Country	:	US
Telephone Number	:	920-366-9814
Fax Number	:

Provider Business Practice Location Address
First Line	:	2605 DEVELOPMENT DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-4240
Country	:	US
Telephone Number	:	920-288-8240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	03/07/2023

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