Provider Demographics
NPI:1164473617
Name:DEERING, JAMIE S (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:S
Last Name:DEERING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8420
Mailing Address - Fax:920-926-8907
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8420
Practice Address - Fax:920-926-8907
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41344-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1164473617Medicaid
WIP01510820OtherRAILROAD MEDICARE
WIK400177943Medicare PIN
WIK400128292Medicare PIN
WI009254375Medicare PIN
WI080185827Medicare PIN