Provider Demographics
NPI:1174673511
Name:INGALLS, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:INGALLS
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 1:26425 LAKELAND AVE S
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:WI
Mailing Address - Zip Code:54893-8343
Mailing Address - Country:US
Mailing Address - Phone:715-866-4271
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:26425 LAKELAND AVE S
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:WI
Practice Address - Zip Code:54893-8343
Practice Address - Country:US
Practice Address - Phone:715-866-4271
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21250000Medicaid
WIE46189Medicare UPIN
WI009045Medicare ID - Type Unspecified