Provider Demographics
NPI:1861570996
Name:DEMOTT, ROBERT KNOX (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KNOX
Last Name:DEMOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:SUITE 100B
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-3496
Practice Address - Fax:920-433-3669
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26772207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30661000Medicaid
B52388Medicare UPIN
WI002150308Medicare Oscar/Certification