Healthcare Provider Details

I. General information

NPI: 1841295862
Provider Name (Legal Business Name): JEFFREY LEMOINE DUNHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 06/06/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 4TH AVENUE
SHELL LAKE WI
54871
US

IV. Provider business mailing address

113 4TH AVENUE
SHELL LAKE WI
54871
US

V. Phone/Fax

Practice location:
  • Phone: 715-468-7833
  • Fax: 715-468-7839
Mailing address:
  • Phone: 715-468-7833
  • Fax: 715-468-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30726
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: