Basic Information
| Provider Information | |||||||||
| NPI: | 1841295862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUNHAM | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | LEMOINE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 FOURTH AVENUE PO BOX 300 | ||||||||
| Address2: | |||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154687833 | ||||||||
| FaxNumber: | 7154687303 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SHELL LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548710336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154682711 | ||||||||
| FaxNumber: | 7154682727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30726 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31592800 | 05 | WI | MEDICAID |