Provider Demographics
NPI:1871585505
Name:WERMUTH, DOUGLAS J (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:WERMUTH
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-281-4466
Mailing Address - Fax:
Practice Address - Street 1:4600 W LOOMIS RD STE 201
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4858
Practice Address - Country:US
Practice Address - Phone:414-281-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30174-20207Y00000X
NC31928207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31496300Medicaid
WI02120-0228Medicare PIN