Provider Demographics
NPI:1124027610
Name:VLACH, ROBERT ELMER JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ELMER
Last Name:VLACH
Suffix:JR
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 1:1265 W AMERICAN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1405
Mailing Address - Country:US
Mailing Address - Phone:920-722-7747
Mailing Address - Fax:
Practice Address - Street 1:1265 W AMERICAN DR STE 100
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-722-7747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29694208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1124027610Medicaid
WIW12073015Medicare PIN
WI000745505Medicare Oscar/Certification
WIW12072015Medicare PIN
WI1124027610Medicaid
WIF23282Medicare UPIN