Provider Demographics
NPI:1639286743
Name:TOLENTINO, PHILLIP R (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:R
Last Name:TOLENTINO
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 1:2405 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-2534
Mailing Address - Country:US
Mailing Address - Phone:262-886-0474
Mailing Address - Fax:262-886-1672
Practice Address - Street 1:2405 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-2534
Practice Address - Country:US
Practice Address - Phone:262-886-0474
Practice Address - Fax:262-886-1672
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46282-20207Q00000X
WI46282207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine