Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 31110-020 | WI |
Y | 208600000X | Surgeon | 31110-020 | WI |
NPI | 1013910785 |
---|---|
Provider Name | Dr. William J Dierberg |
First Address | Green Bay, WI 54304-1946 |
Second Address | Green Bay, WI 54311-4240 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2005 |
Last Update Date | 06/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
31110-020 | MEDICAL LICENSE (01) | WI |
31812800 | (05) | WI |
BD2474500 | DEA (01) | |
F28932 | (02) |