Healthcare Provider Details

I. General information

NPI: 1265510564
Provider Name (Legal Business Name): GLENN F DEVRIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 E FOND DU LAC ST
RIPON WI
54971-9500
US

IV. Provider business mailing address

680 E FOND DU LAC ST
RIPON WI
54971-9500
US

V. Phone/Fax

Practice location:
  • Phone: 920-748-3009
  • Fax: 920-748-3109
Mailing address:
  • Phone: 920-748-3009
  • Fax: 920-748-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number467
License Number StateWI

VIII. Authorized Official

Name: GLENN F DEVRIES
Title or Position: OWNER
Credential: DPM
Phone: 920-748-3009