Provider Demographics
NPI:1992812325
Name:MUTH, DONALD M (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:M
Last Name:MUTH
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 1:908 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2430
Mailing Address - Country:US
Mailing Address - Phone:262-334-8339
Mailing Address - Fax:262-306-7717
Practice Address - Street 1:908 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2430
Practice Address - Country:US
Practice Address - Phone:262-334-8339
Practice Address - Fax:262-306-7717
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15761172V00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31209100Medicaid
WI521833Medicare Oscar/Certification
WI31209100Medicaid