Provider Demographics
NPI:1285621730
Name:CHISM, JEFFREY K (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:K
Last Name:CHISM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-2319
Mailing Address - Country:US
Mailing Address - Phone:715-536-7444
Mailing Address - Fax:715-536-1547
Practice Address - Street 1:410 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2319
Practice Address - Country:US
Practice Address - Phone:715-536-7444
Practice Address - Fax:715-536-1547
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI748-025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43223800Medicaid
WI000000485016OtherWI BLUE SHIELD
WI1285621730OtherBLUE CROSS FEDERAL EMPLOYEE PROGRAM
WI000000485016OtherWI BLUE SHIELD
WI1285621730OtherBLUE CROSS FEDERAL EMPLOYEE PROGRAM