Healthcare Provider Details

I. General information

NPI: 1588624886
Provider Name (Legal Business Name): ROBERT B GAGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NORTH ST
DEFOREST WI
53532
US

IV. Provider business mailing address

10 ASHWOOD CT
MADISON WI
53719-5047
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-3741
  • Fax: 608-846-7898
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22686
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: