Healthcare Provider Details

I. General information

NPI: 1932118536
Provider Name (Legal Business Name): DONALD MASSENBURG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 VOYAGER DR
GREEN BAY WI
54311-8303
US

IV. Provider business mailing address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax: 920-272-1108
Mailing address:
  • Phone: 872-588-3000
  • Fax: 872-588-3021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36115006
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number61024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: