Healthcare Provider Details

I. General information

NPI: 1336254713
Provider Name (Legal Business Name): MICHAEL W. DEGERE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 CAMELOT DR
FOND DU LAC WI
54935-8335
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-8616
  • Fax: 920-926-8098
Mailing address:
  • Phone: 920-926-8340
  • Fax: 920-926-8370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003567
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number841-25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: