Provider Demographics
NPI:1104835156
Name:DEGIOVANNI, JOHN ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:DEGIOVANNI
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 1:35 PRAIRIE AVE
Mailing Address - Street 2:STE. 315
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1500
Mailing Address - Country:US
Mailing Address - Phone:608-643-2431
Mailing Address - Fax:608-643-0048
Practice Address - Street 1:35 PRAIRIE AVE
Practice Address - Street 2:STE. 315
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1500
Practice Address - Country:US
Practice Address - Phone:608-643-2431
Practice Address - Fax:608-643-0048
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18357208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31042800Medicaid
WIB52370Medicare UPIN