Provider Demographics
NPI:1588600696
Name:GASSNER, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:GASSNER
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:PO BOX 3006
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303
Mailing Address - Country:US
Mailing Address - Phone:920-499-1428
Mailing Address - Fax:920-499-5808
Practice Address - Street 1:1789 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-499-1428
Practice Address - Fax:920-499-5808
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI289410202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4723988OtherMICHIGAN MEDICAID
1018745003OtherUNITED HEALTHCARE MEDICAI
MI4767178OtherMICHIGAN MEDICAID
14404OtherDEAN HEALTH
300020918OtherRAILROAD MEDICARE
WI31496900Medicaid
1018745002OtherUNITED HEALTHCARE MEDICAI
567565OtherDEAN HEALTH
072730007Medicare ID - Type Unspecified
070050001Medicare ID - Type Unspecified
P00028702Medicare Oscar/Certification
300020918OtherRAILROAD MEDICARE
WI31496900Medicaid
14404OtherDEAN HEALTH