Provider Demographics
NPI:1528029295
Name:HUTTER, JACK W (DPM)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:HUTTER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-0192
Mailing Address - Country:US
Mailing Address - Phone:262-567-4724
Mailing Address - Fax:262-567-5195
Practice Address - Street 1:422 E SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3749
Practice Address - Country:US
Practice Address - Phone:262-567-4724
Practice Address - Fax:262-567-5195
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI474213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000184450Medicare PIN
WIT62282Medicare UPIN