Healthcare Provider Details

I. General information

NPI: 1003247420
Provider Name (Legal Business Name): MR. ROBERT DONALD WURTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GRAND AVE
WAUSAU WI
54403-6214
US

IV. Provider business mailing address

114 GRAND AVE
WAUSAU WI
54403-6214
US

V. Phone/Fax

Practice location:
  • Phone: 715-845-7175
  • Fax: 715-845-7142
Mailing address:
  • Phone: 715-845-7175
  • Fax: 715-845-7142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1982-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: