Healthcare Provider Details
I. General information
NPI: 1578697520
Provider Name (Legal Business Name): ROBERT JOSEPH DEFATTA MD, PH D, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 03/14/2007
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1490 RIVERS EDGE TRAIL
ALTOONA WI
54720-1495
US
IV. Provider business mailing address
1490 RIVERS EDGE TRAIL
ALTOONA WI
54720-1495
US
V. Phone/Fax
- Phone: 715-828-2368
- Fax:
- Phone: 715-828-2368
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207Y00000X |
| Taxonomy | Otolaryngology Physician |
| License Number | 243412 |
| License Number State | NY |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YP0228X |
| Taxonomy | Pediatric Otolaryngology Physician |
| License Number | 243412 |
| License Number State | NY |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YP0228X |
| Taxonomy | Pediatric Otolaryngology Physician |
| License Number | 55984 |
| License Number State | WI |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YS0012X |
| Taxonomy | Sleep Medicine (Otolaryngology) Physician |
| License Number | 243412 |
| License Number State | NY |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YS0012X |
| Taxonomy | Sleep Medicine (Otolaryngology) Physician |
| License Number | 55984 |
| License Number State | WI |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YS0123X |
| Taxonomy | Facial Plastic Surgery Physician |
| License Number | 243412 |
| License Number State | NY |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YS0123X |
| Taxonomy | Facial Plastic Surgery Physician |
| License Number | 55984 |
| License Number State | WI |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YX0007X |
| Taxonomy | Plastic Surgery within the Head & Neck (Otolaryngology) Physician |
| License Number | 55984 |
| License Number State | WI |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YX0007X |
| Taxonomy | Plastic Surgery within the Head & Neck (Otolaryngology) Physician |
| License Number | 243412 |
| License Number State | NY |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YX0602X |
| Taxonomy | Otolaryngic Allergy Physician |
| License Number | 243412 |
| License Number State | NY |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YX0602X |
| Taxonomy | Otolaryngic Allergy Physician |
| License Number | 55984 |
| License Number State | WI |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YX0901X |
| Taxonomy | Otology & Neurotology Physician |
| License Number | 243412 |
| License Number State | NY |
| # 13 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YX0901X |
| Taxonomy | Otology & Neurotology Physician |
| License Number | 55984 |
| License Number State | WI |
| # 14 | |
| Primary Taxonomy | N |
| Taxonomy Code | 207YX0905X |
| Taxonomy | Otolaryngology/Facial Plastic Surgery Physician |
| License Number | 243412 |
| License Number State | NY |
| # 15 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 207Y00000X |
| Taxonomy | Otolaryngology Physician |
| License Number | 55984-20 |
| License Number State | WI |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
