Healthcare Provider Details

I. General information

NPI: 1427139575
Provider Name (Legal Business Name): KENNETH L BRANSTETTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 DEERWOOD AVE
NEENAH WI
54956-7110
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 920-727-9982
  • Fax: 920-727-9983
Mailing address:
  • Phone: 920-996-3200
  • Fax: 920-738-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51948020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: