Provider Demographics
NPI:1063467652
Name:STADDLER, DANIEL J (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:STADDLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1801
Mailing Address - Country:US
Mailing Address - Phone:608-877-2777
Mailing Address - Fax:608-877-2726
Practice Address - Street 1:225 CHURCH ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1801
Practice Address - Country:US
Practice Address - Phone:608-877-2777
Practice Address - Fax:608-877-2726
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40820-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063467652Medicaid
WI6981OtherDEAN HEALTH INSURANCE
WI32537100Medicaid
WIK400164960Medicare PIN
WI6981OtherDEAN HEALTH INSURANCE
WI741501970Medicare PIN
WI080139615Medicare PIN