Healthcare Provider Details

I. General information

NPI: 1730238890
Provider Name (Legal Business Name): KAGEN DERMATOLOGY CLINIC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 01/01/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W LAWRENCE ST SUITE 409
APPLETON WI
54911-5773
US

IV. Provider business mailing address

100 W LAWRENCE ST SUITE 409
APPLETON WI
54911-5773
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-5138
  • Fax: 920-733-3759
Mailing address:
  • Phone: 920-733-5138
  • Fax: 920-733-3759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number24388
License Number StateWI

VIII. Authorized Official

Name: DR. CHARLES NORMAN KAGEN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 920-733-5138