Provider Demographics
NPI:1578612974
Name:CAPODICE, MARY JO (DO)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:CAPODICE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:526 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3528
Mailing Address - Country:US
Mailing Address - Phone:920-457-0318
Mailing Address - Fax:
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-459-1459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI341162083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B53350Medicare UPIN