Provider Demographics
NPI:1629068135
Name:CUNDIFF, JERALD E (MD)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:E
Last Name:CUNDIFF
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 1:800 WEST AVE S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8806
Mailing Address - Country:US
Mailing Address - Phone:608-791-9871
Mailing Address - Fax:608-791-7852
Practice Address - Street 1:101 E MILLER RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081
Practice Address - Country:US
Practice Address - Phone:815-625-4790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38957207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN291023300Medicaid
WI32545800Medicaid
WI0262Medicare PIN