Provider Demographics
NPI:1558456749
Name:MATTEUCCI, JOHN C JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:MATTEUCCI
Suffix:JR
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 1:6127 GREEN BAY ROAD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2973
Mailing Address - Country:US
Mailing Address - Phone:262-653-9221
Mailing Address - Fax:262-653-9229
Practice Address - Street 1:6127 GREEN BAY ROAD
Practice Address - Street 2:SUITE 600
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2973
Practice Address - Country:US
Practice Address - Phone:262-653-9221
Practice Address - Fax:262-653-9229
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38866208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32467300Medicaid
WI32467300Medicaid
F10182Medicare UPIN