Provider Demographics
NPI:1003834250
Name:HUBERTUS, GREGORY N (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:N
Last Name:HUBERTUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 N MILITARY AVE
Mailing Address - Street 2:STE 10
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4569
Mailing Address - Country:US
Mailing Address - Phone:920-498-2020
Mailing Address - Fax:920-498-2269
Practice Address - Street 1:550 N MILITARY AVE
Practice Address - Street 2:STE 10
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4569
Practice Address - Country:US
Practice Address - Phone:920-498-2020
Practice Address - Fax:920-498-2269
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV07501Medicare UPIN
WI000487970Medicare ID - Type Unspecified
1282330001Medicare NSC