Healthcare Provider Details

I. General information

NPI: 1598812653
Provider Name (Legal Business Name): DAVID J OGREN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 MARKETPLACE DR STE 212
FITCHBURG WI
53719-5325
US

IV. Provider business mailing address

2840 OSMUNDSEN RD
FITCHBURG WI
53711-5138
US

V. Phone/Fax

Practice location:
  • Phone: 608-609-6709
  • Fax: 608-238-3159
Mailing address:
  • Phone: 608-609-6709
  • Fax: 608-238-3159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2680-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: