Provider Demographics
NPI:1902911472
Name:DEGERMAN, GARY R (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:DEGERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1020 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868
Practice Address - Country:US
Practice Address - Phone:715-236-8312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34216207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31944300Medicaid
WI31944300Medicaid
WI003705090Medicare ID - Type Unspecified