Basic Information
| Provider Information | |||||||||
| NPI: | 1033172796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OETH | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8007 EXCELSIOR DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295247 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539252401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206235226 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19299 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31029800 | 05 | WI | MEDICAID |