Provider Demographics
NPI:1083141667
Name:JOSEPH, JESU (DO)
Entity Type:Individual
Prefix:
First Name:JESU
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:DO
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 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:773-594-7975
Practice Address - Street 1:2404 CHARLES ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1602
Practice Address - Country:US
Practice Address - Phone:779-696-7910
Practice Address - Fax:815-227-5515
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036-150252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program