Provider Demographics
NPI:1396776589
Name:HANDTKE, ROGER A (DO)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:A
Last Name:HANDTKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13380 W TREPANIA RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-2186
Mailing Address - Country:US
Mailing Address - Phone:715-638-5100
Mailing Address - Fax:715-634-6107
Practice Address - Street 1:ESSENTIA HEALTH SPOONER CLINIC
Practice Address - Street 2:1180 CHANDLER DRIVE
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801
Practice Address - Country:US
Practice Address - Phone:715-635-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001222A207Q00000X
WI63316207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100209300Medicaid
IN100209300Medicaid
IN390380FMedicare ID - Type Unspecified
WIK400186404Medicare PIN
INE73760Medicare UPIN