Provider Demographics
NPI:1871587899
Name:AGNEBERG, BRUCE E (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:AGNEBERG
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 1:5395 EAST CHERYL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5395
Mailing Address - Country:US
Mailing Address - Phone:608-276-4660
Mailing Address - Fax:608-276-4660
Practice Address - Street 1:5395 EAST CHERYL PARKWAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-5395
Practice Address - Country:US
Practice Address - Phone:608-246-4660
Practice Address - Fax:608-246-4660
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51117-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine