Basic Information
| Provider Information | |||||||||
| NPI: | 1003985284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DU BRAY | ||||||||
| FirstName: | KANSAS | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | S2845 WHITE EAGLE LANE | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083551240 | ||||||||
| FaxNumber: | 6083559643 | ||||||||
| Practice Location | |||||||||
| Address1: | S2845 WHITE EAGLE LANE | ||||||||
| Address2: | |||||||||
| City: | BARABOO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083551240 | ||||||||
| FaxNumber: | 6083566347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 42772020 | WI | X | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 42772020 | WI | X | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 14466 | 01 | DEAN HEALTH PLAN | OTHER | 34175500 | 05 | WI | MEDICAID | P00054953 | 01 | RAILROAD RETIREMENT | OTHER |