Provider Demographics
NPI:1265489264
Name:GAUTHIER, MICHELLE LOUISE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOUISE
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9697 SAINT CATHERINES DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-2118
Mailing Address - Country:US
Mailing Address - Phone:262-577-8320
Mailing Address - Fax:262-577-8372
Practice Address - Street 1:9697 SAINT CATHERINES DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2118
Practice Address - Country:US
Practice Address - Phone:262-577-8320
Practice Address - Fax:262-577-8372
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43499900Medicaid
WI081091455OtherMEDICARE RR