Individual
LOREN C FUGLESTAD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2714 RIVERVIEW DR, GREEN BAY, WI 54313-6715
(920) 430-4760
Mailing address
2714 RIVERVIEW DR, GREEN BAY, WI 54313-6715
(920) 430-4760
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
35673
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
35673
LICENSE
WI
01
—
P01404701
RAIL ROAD MEDICARE
WI
Enumeration date
12/05/2005
Last updated
02/19/2015
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