Provider Demographics
NPI:1477607612
Name:GOUNTIS, BOB MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:MATTHEW
Last Name:GOUNTIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 N MAYFAIR RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3442
Mailing Address - Country:US
Mailing Address - Phone:414-778-1455
Mailing Address - Fax:414-810-4052
Practice Address - Street 1:1033 N MAYFAIR RD
Practice Address - Street 2:SUITE 303
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3442
Practice Address - Country:US
Practice Address - Phone:414-778-1455
Practice Address - Fax:414-810-4052
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3517-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000275081Medicare ID - Type Unspecified