Provider Demographics
NPI:1154372092
Name:FAUST, DEIDRE L (MD)
Entity type:Individual
Prefix:DR
First Name:DEIDRE
Middle Name:L
Last Name:FAUST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEIDRE
Other - Middle Name:L
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300/ATTN. KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:13133 N PORT WASHINGTON ROAD
Practice Address - Street 2:SUITE G18
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2420
Practice Address - Country:US
Practice Address - Phone:262-243-5000
Practice Address - Fax:262-243-2527
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44807-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154372092Medicaid
WI1154372092Medicaid