Provider Demographics
NPI:1316940927
Name:GREMBAN, DOUGLAS C (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:GREMBAN
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 1:14353 STATE HIGHWAY 32 64
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN
Mailing Address - State:WI
Mailing Address - Zip Code:54149-9656
Mailing Address - Country:US
Mailing Address - Phone:715-276-1600
Mailing Address - Fax:715-276-1800
Practice Address - Street 1:14353 STATE HIGHWAY 32 64
Practice Address - Street 2:
Practice Address - City:MOUNTAIN
Practice Address - State:WI
Practice Address - Zip Code:54149-9656
Practice Address - Country:US
Practice Address - Phone:715-276-1600
Practice Address - Fax:715-276-1800
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23967-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11014110Medicaid
WI1568552958OtherMPCC NPI
WI1851477913OtherCMH NPI
WI521310Medicare Oscar/Certification
WI11014110Medicaid