Organization
DEFATTA ENT & FACIAL PLASTIC SURGERY SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROBERT JOSEPH DEFATTA MD, PH D, FACS (OWNER)
(715) 828-2368
Entity
Organization
Contact information
Practice address
1490 RIVERS EDGE TRAIL, ALTOONA, WI 54720-1495
(715) 828-2368
(715) 726-2087
Mailing address
1490 RIVERS EDGE TRAIL, ALTOONA, WI 54720-1495
(715) 828-2368
(715) 726-2087
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
55984-20
WI
261QM2500X
Medical Specialty Clinic/Center
55984-20
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100016459
—
WI
01
—
1578697520
NPI
WI
01
—
1790931707
NPI PROVIDER
WI
Enumeration date
02/17/2014
Last updated
05/05/2014
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