Basic Information
| Provider Information | |||||||||
| NPI: | 1083657555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTLER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 SCHEURING RD | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541151067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206835278 | ||||||||
| FaxNumber: | 9206832131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 29339020 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207NS0135X | 29339020 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207ND0101X | 29339020 | WI | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 29339-020 | 01 | WI | STATE LICENSE | OTHER | 382000019 | 01 | WI | MEDICARE | OTHER | BB4957239 | 01 | WI | DEA | OTHER | 32318400 | 05 | WI | MEDICAID | P00218264 | 01 | WI | RAILROAD MEDICARE | OTHER |