Provider Demographics
NPI:1679741318
Name:PAMELA G DOBSON DO
Entity type:Organization
Organization Name:PAMELA G DOBSON DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:DOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:920-445-0660
Mailing Address - Street 1:211 N BROADWAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2757
Mailing Address - Country:US
Mailing Address - Phone:920-445-0660
Mailing Address - Fax:920-445-0661
Practice Address - Street 1:211 N BROADWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2757
Practice Address - Country:US
Practice Address - Phone:920-445-0660
Practice Address - Fax:920-445-0661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27190-021207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30024100Medicaid
WI0709930001Medicare NSC
WICJ4780Medicare PIN