Provider Demographics
NPI:1346204757
Name:DECARLO, JOHN DOMINIC (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DOMINIC
Last Name:DECARLO
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 1:16650 W BLUEMOUND RD # 400B
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5920
Mailing Address - Country:US
Mailing Address - Phone:414-476-5120
Mailing Address - Fax:414-476-5181
Practice Address - Street 1:16650 W BLUEMOUND RD # 400B
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5920
Practice Address - Country:US
Practice Address - Phone:414-476-5120
Practice Address - Fax:414-476-5181
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21652-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391382883015OtherBLUE CROSS BLUE SHIELD
WI30261600Medicaid
WI30261600Medicaid
WI000032188Medicare ID - Type UnspecifiedKENOSHA LOCALITY
WI000001608Medicare ID - Type UnspecifiedMILWAUKEE LOCALITY