Provider Demographics
NPI:1417982448
Name:SHOLL, JOHN SARGENT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SARGENT
Last Name:SHOLL
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 1:2133 TO TO TOM DR
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-9661
Mailing Address - Country:US
Mailing Address - Phone:715-928-2650
Mailing Address - Fax:
Practice Address - Street 1:2133 TO TO TOM DR
Practice Address - Street 2:
Practice Address - City:LAC DU FLAMBEAU
Practice Address - State:WI
Practice Address - Zip Code:54538-9661
Practice Address - Country:US
Practice Address - Phone:715-928-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51208-20207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14886Medicare UPIN