Basic Information
| Provider Information | |||||||||
| NPI: | 1639277429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATTON | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 163 E HAGERMAN LAKE RD | ||||||||
| Address2: | |||||||||
| City: | IRON RIVER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499357923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062653131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1615 MAPLE LN | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548063610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855500 | ||||||||
| FaxNumber: | 7156824022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31958 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301061515 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 4301061515 | MI | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | BP2711605 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | BP2711605 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65B87PA | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 1639277429 | 05 | MI | MEDICAID | 104142720 | 05 | MI | MEDICAID | 31756100 | 05 | WI | MEDICAID |