Provider Demographics
NPI:1275521965
Name:GASSNER, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:GASSNER
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 1:2920 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1944
Mailing Address - Country:US
Mailing Address - Phone:920-458-3791
Mailing Address - Fax:920-458-3783
Practice Address - Street 1:2920 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1944
Practice Address - Country:US
Practice Address - Phone:920-458-3791
Practice Address - Fax:920-458-3783
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27632207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30754800Medicaid
061710001Medicare ID - Type Unspecified
WI30754800Medicaid