Provider Demographics
NPI:1861592172
Name:DEWIRE, DOUGLAS M (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:DEWIRE
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 1:1111 DELAFIELD ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3417
Mailing Address - Country:US
Mailing Address - Phone:262-446-3593
Mailing Address - Fax:262-547-0379
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 207
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-446-3593
Practice Address - Fax:262-547-0379
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29617208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31928700Medicaid
WI391345728029OtherANTHEM BLUE CROSS BLUE SH
WIK400173776Medicare PIN
WI391345728029OtherANTHEM BLUE CROSS BLUE SH
WI31928700Medicaid