Provider Demographics
NPI:1295837797
Name:PINKONSLY, WILLIAM RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:PINKONSLY
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 1:1300 SOUTH DRIVE
Mailing Address - Street 2:PO BOX 0009
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-237-2043
Practice Address - Street 1:N2934 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982
Practice Address - Country:US
Practice Address - Phone:920-787-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48295207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4136296002OtherUHC MA DIAMOND PROV #
WIP00252127OtherRR MEDICARE PROV #
WI43523600Medicaid
WI47763OtherNETWORK HEALTH PROV #
WI48295OtherSTATE LICENSE #
WI43523600Medicaid
WI48295OtherSTATE LICENSE #