Healthcare Provider Details

I. General information

NPI: 1609946292
Provider Name (Legal Business Name): RENE MARTIN EARLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 S WEBSTER AVE STE 241
GREEN BAY WI
54301-2158
US

IV. Provider business mailing address

2221 S WEBSTER AVE STE 241
GREEN BAY WI
54301-2158
US

V. Phone/Fax

Practice location:
  • Phone: 920-965-0345
  • Fax: 920-273-6011
Mailing address:
  • Phone: 920-965-0345
  • Fax: 920-273-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036044864
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number54674-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: