Basic Information
| Provider Information | |||||||||
| NPI: | 1386631000 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENISH | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 N DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539592214 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 N DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | REEDSBURG | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539592214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6085246477 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41513 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32585700 | 05 | WI | MEDICAID |