Healthcare Provider Details

I. General information

NPI: 1295785483
Provider Name (Legal Business Name): IRA S KASTENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 W SEWARD ST
POYNETTE WI
53955-9584
US

IV. Provider business mailing address

PO BOX 97
POYNETTE WI
53955-0097
US

V. Phone/Fax

Practice location:
  • Phone: 608-635-4343
  • Fax: 608-635-7094
Mailing address:
  • Phone: 608-635-4343
  • Fax: 608-635-7094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20342-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: