Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 39133 | WI |
N | 207R00000X | Internist | 39133 | WI |
N | 111NI0900X | Internist | 39133 | WI |
Y | 207RA0401X | Internist - Addiction Medicine | 39133 | WI |
NPI | 1346212545 |
---|---|
Provider Name | Dr. Ian R Powell |
First Address | Oconomowoc, WI 53066-4500 |
Second Address | Oconomowoc, WI 53066-4500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2006 |
Last Update Date | 20/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
32580600 | (05) | WI |
H05048 | (02) |